The Man Who Touched His Own Heart

by Rob Dunn

  Sones climbed out of the hole and started looking for a scalpel to cut into the patient’s chest. The man’s heart slowed, its rhythmic pacing diminished from peaks to mere hills. Sones yelled for him to cough. “Cough!” The dye would be physically moved out of the arteries by the coughs; some of it anyway, maybe. Today, Sones might have shocked the patient’s chest, but even such simple technology had not yet been invented. If his heart stopped all the way, as it was clearly about to, the only choice would be to cut him open, which would take longer than the three minutes one has before the brain loses too much oxygen and the patient dies. The man was going to die.

  And then he didn’t.

  Slowly, the man’s heart started to beat normally again, of its own accord. Sones, who had breathed only enough to yell, “Cough, cough, cough,” inhaled and began to smile and yell, this time with joy. Something very, very good had just happened. The man had lived, but the more lasting impact would be that Sones had just unintentionally pioneered the main method that is still used to see all of the heart.

  Many surgeons in that situation would have paused to be thankful that the patient had lived and then moved on. Initially, Sones too, in his own telling, “could feel only relief and gratitude.” But soon he realized he had seen what was possible; he had seen the future. He could inject dye into the coronary artery and not kill the patient. This patient, yes, had been close to dying, but it would be a matter of tweaking how much dye was used and how. Sones wrote of the moment, “I began to think that this accident might point the way for the development of a technique which was exactly what we had been seeking… If a human could tolerate such a massive injection of contrast [dye] directly into a coronary artery, then it might be possible to accomplish this kind of opacification with smaller amounts of a more dilute contrast. With considerable fear and trepidation we embarked on a program to accomplish this objective.”

  Sones’s initial discovery came of a mistake, but as he moved forward to perfect this discovery, he would make no more. The proof would be in the subsequent attempts, of which there would be many. An hour later, he was planning to repeat the “mistake.” A mere two days later, Sones did. It worked again. It worked the next time too. Over the next years, Sones repeated the procedure again and again, inventing a new catheter to make it easier and also relying on progressively faster film and better amplifiers along with direct defibrillators (to restart the heart without cutting open the chest) to make everything safer. By 1962, Sones reported on the use of dye in the coronary arteries in 1,020 patients.23 By 1967, Sones and his colleagues at the Cleveland Clinic had performed the procedure, which has come to be called a coronary angiogram (literally, a “heart drawing,” from angio-, “heart,” and -gram, “drawing or writing”), 8,200 times. Sones’s fame grew in light of the coronary angiogram. Teaching others how to see the heart’s hidden canals gave him pleasure. Yet Sones could not fix the problems he was seeing in the heart. For as fast as his new method of seeing spread, first within the Cleveland Clinic and then around the world, so too spread the realization of something that had been known but not yet obvious: the arteries that fed the heart seemed to clog nearly inevitably. Maybe this was just, as da Vinci had described it, the sweet death, but Sones had seen many heart attacks, and while some could be considered sweet, clean ends to fruitful lives, they were not all that way. But more important, clogged arteries, sweet or not, were not rare.

  By 1816, William Black had discovered by looking at cadavers that the cause of chest pain, angina, seemed to be the hardening and thickening of the coronary arteries (da Vinci noted atherosclerosis but does not appear to have ever focused on atherosclerosis of the coronary arteries in particular). Chest pain was the only real sign (short of death) that these arteries had clogged, and so, to the extent to which the incidence of clogged coronary arteries was considered, it was thought to be synonymous with the incidence of angina. But in his angiograms, Sones saw that it was far more common than anyone had thought; atherosclerosis was evident even in those with no symptoms. In a healthy heart, the vessels—the aorta and the main arteries—would all be black. The angiogram would look like a twisted black flower, with the strong dark lines of the coronary arteries arching over the top. The black was the color of the dye indicating blood. But in many of the thousands of people whose angiograms Sones studied, Sones saw white. The white patches were the places where the dye did not go, where the great and necessary arteries were clogged; the white was the plaque, the thing that eats the heart.

  There were two problems moving forward. The first was that, at least as of the time Sones started performing his coronary angiography, there were no treatments for heart disease due to clogged coronary arteries—none. The history of treating heart disease was, until that moment, a history of magic and hope. In 1492, Pope Innocent VIII was suffering from angina. By some accounts, he had three ten-year-old boys brought in. The boys were hooked up to the pope so that he could receive their young vital blood orally. The boys and, ultimately, the pope died.24 Several centuries later, when Charles II of England was found to be suffering from what seems, in retrospect, to have been either heart disease or the early stages of a brain hemorrhage (the mind’s rotten kin to heart disease, as we’ll explore later), he was bled. By 1958, the fate of someone afflicted with heart disease was little different—the treatment was bed rest and a glass of wine. When a man or a woman came to the doctor suffering from angina pectoris (angina is Greek for “strangling” and pectoris for “chest”), Sones could now, finally, see what was causing the strangling; he could even diagnose clogged coronary arteries before the strangling. He was just unable to do a damned thing about it.

  In 1958 (the date of Sones’s accidental angiogram), surgeries of the heart had become more common, but they were still special cases. Wounds could be stitched up. A few congenital problems could be repaired, a few holes mended, but the vast majority of heart problems were simply irreparable. These were humble times,25 which makes what happened next all the more amazing.

  Over the next ten years, surgeons would move into the heart with what in retrospect one must describe as wild recklessness. Many even said as much at the time.26 The next step for Sones would be to try to mend coronary arteries clogged by atherosclerosis or to prevent the atherosclerosis in the first place. But something else was needed before he could do so with frequency and ease: someone had to figure out a better way to work on the heart. The heart, as of the time of Sones’s discovery, could still be operated on for only three to six minutes. After that, the lack of oxygen to the brain would kill the patient. Six minutes was about twenty minutes too few for ambitious interventions such as those that might mend the coronary arteries.

  Someone needed to figure out a way to allow longer surgeries. The first attempts focused on chilling the body and, in essence, slowing everything down so that six minutes might be turned into a dozen. This worked, but not always and only with incredible difficulty (initially, the patient had to be dunked in ice, though later approaches would focus on just chilling the heart itself). But there was another possibility. Some surgeons thought one might be able to create a kind of machine that would keep oxygen moving through the blood while the heart was opened up. It would be, if only for ten minutes, a replacement for the heart, and ten minutes might be long enough to do something about clogged coronary arteries and maybe a great deal else.

  6

  The Rhythm Method

  One night in 1930 at Massachusetts General Hospital, a teaching hospital of Harvard Medical School, John Gibbon’s mentor, Dr. Edward Churchill, called Gibbon to the room of a female patient who was pale, tired, and short of breath. The woman had been through gallbladder surgery two weeks earlier. Churchill moved the patient to the operating room and asked Gibbon and a young technician, Mary “Maly” Hopkinson, to watch her through the night, recording her pulse and respiration every fifteen minutes. The patient appeared to be suffering from an embolism (a blockage of coagulated blood) in the pulmonary artery
, the big vessel that connects the right ventricle of the heart to the lungs. The embolism was almost certainly caused by the earlier surgery. The predicament was dire. If the blockage remained, it would prove fatal, choking off too much of the blood flow to the lungs (and ultimately back to the heart and brain). But few surgeons had ever successfully removed an embolism and none ever in the United States. Churchill decided he would try, but only if the patient’s blockage became complete and she lost consciousness, in essence fating her to death in the absence of intervention.

  Gibbon was tasked with the job of alerting Churchill if the patient’s condition deteriorated. He was waiting for the patient to nearly die. All night, he and Hopkinson kept vigil, by turns talking with the patient and watching her sleep. Then, at eight in the morning, the patient lost consciousness. Churchill was called. He ran to the room, cut into the patient’s chest, and pushed apart her ribs; he had just three minutes until she would suffer brain death. The operation was done by feel; Churchill could not see through the blood spitting up out of the beating heart, but he found the pulmonary artery and, once there, several clots, which he successfully removed. But it was too late. The patient had gone too long without oxygen reaching her brain and never regained consciousness.

  Emergency surgery was a kind of tragic circus, one so dangerous no one should ever want to look, and yet, as a young surgeon, Gibbon had to. He looked at the body and cried. He was haunted by that night. As he later wrote, “During that long… vigil the idea occurred to me that the patient’s life might have been saved if some of her cardiorespiratory functions might be taken over by an extracorporeal blood circuit.”1 In response to this experience, he might have decided to return to writing or some other career. Instead, he would focus the next years of his life on trying to build a heart-lung machine that would supply oxygenated blood to a patient’s organs when her heart and lungs could not do so, at least for the duration of a surgery (initially, the surgery he imagined was embolism removal, but before long he realized that such a device would also permit a whole new field of heart surgery). He also married the technician, Maly Hopkinson, who would collaborate with him on the dream that from the very beginning she shared. Gibbon was a good man who wanted to do great things with his life, with Maly.2

  Born on September 29, 1903, John “Jack” Heysham Gibbon was fated to be part of a fifth generation of physicians.3 His family had spent more than a hundred years mending those who needed it, mending and consoling. In that entire time, nothing the family had done for problems of the heart had changed. One ineffective medicine might be favored over another, but the end result was the same. Patients sick at heart were sent home, urged to rest and take one or another potion. Gibbon was born to the first generation in which all of that might change.

  When Gibbon entered Princeton University, he did not want to be a doctor. He studied French literature. He traveled through France with his sister. He was, in his sister’s telling, “afire” with “intellectual interests and philosophy.”4 He wanted to be a creative writer or a painter. He graduated at the age of nineteen, a free spirit in the world headed for a bohemian life. But his father told him, “If you don’t want to practice you needn’t, but you won’t write worse for having [your medical degree].” Gibbon either was convinced or acquiesced and so entered medical school at Jefferson College in Philadelphia, graduating at twenty-three in 1927.

  It was just three years after leaving Jefferson College that Gibbon found himself standing beside Churchill and Maly Hopkinson looking at the dead patient who would motivate him to build a heart-lung machine. In 1930, few imagined a heart-lung machine would be possible, and so when Gibbon, just twenty-seven, and Maly began to consider how to build such a machine, they were inventing from scratch. The two used a lab on the top floor of the Bulfinch building of Massachusetts General Hospital and gathered parts from any lab that offered them. They tested their ideas and makeshift equipment on stray cats they caught together on the streets of Boston; the lungs and hearts of cats are small, and so it was an easier first challenge to produce a machine that would pump and aerate the small quantity of blood necessary. But even for cats, the challenges were considerable. Somehow the machine had to provide oxygen to the blood without damaging red blood cells; it had to be incredibly gentle and forceful at once.

  In 1931, Jack and Maly returned to Philadelphia, where Jack took a job as an assistant surgeon at Pennsylvania Hospital (he was simultaneously a fellow at the University of Pennsylvania School of Medicine). Having landed a more permanent job, Gibbon wanted to work on actually building the machine, but there just wasn’t much time, and so the dream was on hold (except at the dinner table, where Jack and Maly talked about it constantly). Gibbon’s colleagues appear to have liked him and Maly but thought their scheme unlikely to succeed. Three years into his position, Gibbon decided to move, again, back to work with Churchill at Massachusetts General Hospital, where he was promised space and time to work on a heart-lung machine. Maly was promised a position as Gibbon’s technical assistant. Once back at Mass. General, within a year, Gibbon and Maly had a prototype. The Gibbons tried it on some more stray cats. At first, nearly all the cats died, and what was more, they died tragic, awful deaths. Gibbon and Maly were demoralized, but by the end of 1934, still their first year back in Boston, one cat survived, with no ill effects, for twenty minutes. Twenty minutes! In their enthusiasm the two did a jig beside the cat, squealing with a sense of what they had done but also of what was to come; they had done it! Gibbon would later say of that moment, “Nothing in my life has duplicated the ecstasy and joy of that dance with [Maly] around the laboratory.”

  The Gibbons did not publish their findings (they would wait another three years), but word had spread. On the basis of the successes with cats, the University of Pennsylvania Medical School offered Jack Gibbon a position as a surgical research fellow in the Harrison Research Labs. He took it. Once back home in Philadelphia, he and Maly continued to make progress working with both cats and dogs, though they spent less time in the lab themselves and more time managing a team, the sort of team necessary to actually make such a contraption work. The machine was refined. The cats and, to a lesser extent, dogs were brought off the machine more predictably and in a more or less healthy condition. Jack, Maly, and a growing number of assistants were on the verge of having a machine ready to test on humans. And whereas the two originally imagined the machine would be used primarily for surgeons to work on embolisms, it was increasingly clear to all involved that it would also allow an entire field of other heart surgeries, “impossible” surgeries.5 The machine itself was, as Gibbon put it, an assemblage of “metal, glass, electric motors, water baths, electrical switches, electromagnets, etc… [that] looked for all the world like some ridiculous Rube Goldberg apparatus.” But it worked, at least on relatively small animals with relatively small lungs. Then World War II began.

  Jack Gibbon volunteered as a reserve officer despite feeling like he was getting closer and closer to the breakthrough to which he and Maly had devoted their professional lives. He was a man drawn to duty. It was, apparently, the other thing his family did. Gibbon’s maternal grandfather (the only grandparent he had known growing up) fought in the Civil War, as did a great-uncle, another John Gibbon, who was a prominent Union commander in the Iron Brigade. His father volunteered for World War I and the Spanish-American War.

  Gibbon became chief of surgical services to the 364th Station Hospital in the Pacific theater. There, he improvised out of necessity. This improvisation inside the body allowed him to continue to think about his machine and heart surgery even while he was away from the lab. When he came home to his wife and family four years later, medically discharged due to a herniated disk, he was an even more qualified surgeon than he had been before the war. He was recruited for a more prestigious job as professor and director of surgical research at Jefferson College (which he accepted in January of 1946) and readied to continue work on his great machine.

  Wit
h the end of the war, the global landscape changed politically, but it also changed in terms of science and medicine. The United States had become the power in discovery, and this power made many impossible things, Gibbon’s heart-lung machine included, more likely. Whereas before the war he often struggled to find support for the work on his machine, after the war, developing the machine became a major endeavor at Jefferson Medical College Hospital, one with which other doctors were eager to assist. In fact, some had “assisted” in his absence (Clarence Dennis had assembled his own heart-lung machine, based on Gibbon’s design, and tried it in the operating theater).

  With the help of a growing lab, Gibbon improved the machine he and Maly had been working on. Maly and Gibbon had less to do with the hands-on aspects of this new phase of research; they hired and enlisted new colleagues more expert than they were at the details of what was necessary. Soon the new team had a new prototype that, like the one he designed before the war, would work, but still only mostly. The device used a pump to oxygenate blood that then traveled through a series of tubes, cannulas, and valves. But as the blood moved through the pump, it would clog or, worse, pick up infections. Oxygen bubbles also appeared, which could cause brain embolisms and a death worse than the one the machine was meant to prevent. Gibbon was trying to replace the heart’s elaborate subtlety with a crude machine, and the lungs’ great networks with something even cruder. The machine resembled the heart and lungs in the same way that a man with feathers glued to his arms resembles a bird.6

  The team was able to fix the pump by replacing it with a device that would squeeze the tubes of the heart-lung machine the way that muscles around the intestines squeeze (by rolling over the tube and then rolling again), which ushered the blood along. But there was still oxygen getting into the heart and then hiding behind the valves. Dr. Frank Alibritten,7 whom Gibbon had hired, had an idea. He could make a vent for the air, a kind of chimney. The vent would be stabbed through the muscle of the left ventricle.