Blood and Guts

by Richard Hollingham

  Oil lamps burnt in the windows, and a small group of people had gathered around the door of the small wooden cabin. Several women were sobbing; another was trying to corral a group of bewildered- looking children. The older men hung back in the shadows, chewing on tobacco, mumbling and shaking their heads. A man and a woman stood by the door clasping each other's hands tightly.

  Dr Parker and Dr Wilkerson were waiting outside and ushered Hill into the cabin's solitary room. The building was little more than a long shed, sparsely furnished with a table, hard wooden chairs and an iron stove in the corner. Then Hill saw the boy. Thirteen-year-old Henry Myrick was barely alive. He lay on the bed, his skin almost translucent, his breathing imperceptible.

  Myrick had been stabbed with a knife at five o'clock that afternoon. The circumstances of the crime were not clear, but Hill found it hard to believe that the boy had been in a fight – his appearance was far too delicate for that. Dr Parker and Dr Wilkerson had been called six hours after the injury. Now, almost eight hours after the stabbing, Hill leant forward to examine the boy.

  The knife blade had entered the boy's chest about a quarter of an inch to the right of the left nipple. Hill put his fingers to the wound and could see that it went deep. With every weak beat of the boy's heart, there was a bright red stream of blood, as if someone were squeezing a blood-soaked sponge. The skin was marked with a triangular patch of dullness, a bruise suggesting that most of the blood was being squeezed out inside the boy's chest. The boy's hands, lips and nose were cold. Hill felt for a pulse but could find hardly any sign of it. Even when he bent close, the heartbeat was barely audible.

  The boy was slipping in and out of consciousness. Hill shook him gently and asked him how he felt. When the boy spoke, his voice was weak. He was clearly in great pain, but perhaps not beyond help. Hill went outside to consult Henry's parents. The surgeon was offering them a glimmer of hope that their son might survive. They agreed that Hill could operate.

  When it came to the heart, Dr Luther Leonidas Hill, MD was one of the best-qualified doctors in the southern United States, if not the world. Obtaining his first medical degree at the age of nineteen, he had studied at medical schools in Alabama, New York and Philadelphia. From September 1883 until March 1884 Hill had even spent six months in London, being instructed by that great father of modern surgery Joseph Lister. Since returning to his native Montgomery, Hill had devised his own medical speciality: the study of heart wounds. Two years previously he had published a report drawing together the known cases of repairing a wounded heart. Hill had studied heart operations: he knew how they should be done and he knew how likely the patients were to survive. However, this was the first time he had seen a wounded heart for himself.

  Hill asked for two lamps to be placed near the cabin's single table. The other doctors started to clean the area around it with carbolic as best they could. Hill lifted Henry from his bed and placed him on the hard surface. By now the cabin was becoming crowded with medical men. Hill's brother had arrived, as had a Dr Robinson, who was preparing to administer the chloroform anaesthetic. Hill doused his instruments in carbolic, then laid them out beside the table. Robinson took his dropper bottle, applied the measured amount of chloroform to the mask and held it over the boy's face. At one o'clock in the morning in a battered wooden cabin Dr Luther Hill was about to attempt one of the first operations on a beating human heart.

  Hill raises his knife and makes his first cut through the skin to the left of the sternum, the breastbone that runs down the centre of the chest. It is a deep incision. He continues this cut outwards from the sternum along the third rib from the top. He must cut through the skin, the connective tissue beneath and the muscles covering the ribs. He makes a second incision along the sixth rib on the left-hand side, then joins these two lateral incisions together with a further vertical cut. Hill has carved three sides of a rectangle into the boy's flesh, the lines of incision now outlined in red as blood seeps out. This will become Hill's door to the heart.

  Hill picks up some bone nippers and begins to cut through the three exposed ribs along the vertical incision in the boy's chest. The cutters go through the bone of each rib cleanly with a brittle snap. Ribs are attached to the sternum by pieces of cartilage, so Hill can lift up the skin where he has cut the bone and use the cartilage as a hinge. He gently pulls up the flap and bends it back, opening a door of skin and severed ribs to expose the heart.

  The heart. The size of a large fist, this hollow muscular pump beats around seventy times every minute, 100,000 times a day, 36 million times a year. Over a normal lifetime the human heart will beat more than 2.5 billion times. Every minute it pumps some eight pints of blood around the body through more than 54,000 miles of blood vessels. Stop this circulation of blood for much more than four minutes and the lack of oxygen leads to permanent brain damage. Fail to repair a major wound or cut into the heart and a human can bleed to death within a minute.

  Hill looks down at Henry's beating heart. Its protective fibrous sack – the pericardium – is bulging out, filling with blood from the wounded organ. The heart is struggling against the pressure of this blood pushing against it. The pericardium looks as if it could burst, and with every beat the situation is only getting worse. Hill slits the wall of the pericardium, enlarging the original stab wound. Blood pours out, but with the pressure on the heart released, the heartbeat grows stronger. This is a good sign.

  Hill asks his brother to reach into the pericardium and pull the heart upwards towards the opening in the boy's chest. Finally, Hill can see where the wound has penetrated. The knife had cut through the thick wall of the left ventricle, one of the two long chambers of the heart. From the left ventricle oxygenated blood leaves the heart at high pressure to circulate through the body.

  Hill's brother cups the beating heart in his hand. A jet of blood spurts from the wound with every pulse. It is difficult to keep the organ steady – the blood makes it slippery as it jumps in his palm, but he does his best. Dr Hill reaches for his curved suture needle and some catgut thread and begins to stitch the wound together. As he works, the flow of blood gradually lessens; the gap closes and the blood begins to coagulate.

  The heart keeps beating.

  His brother gently slips the heart back within the pericardium and Hill pours salt solution over it to both clean the cavity and act as a mild antiseptic. He closes the cartilage hinge and stitches the flap of bone, muscle and skin back in place. Forty-five minutes have elapsed and the operation is over. Hill lifts Henry back to the bed. The boy has a slight fever and is slipping in and out of consciousness, but his heartbeat remains strong.

  Three days after the operation, Henry's condition starts to improve. Fifteen days later he is allowed to sit up. Within a few weeks he has fully recovered and can show off his scar with pride. Hill is delighted; he is the first American surgeon to successfully cure a wound to the heart.

  When Hill published a report of the case later that year, he included it in a table of similar operations undertaken between 1896 and 1902. For any aspiring heart surgeons the table would make depressing reading. There were wounds from knives, pistol shots and even scissors (in this case the victim had been stabbed a total of six times). Some of the patients received anaesthetic, some did not. Some were operated on immediately, some were not. It was difficult to draw any firm conclusions about the circumstances, given that so many of the operations resulted in death. Patients died of haemorrhages or infection, others bled to death on the operating table. Of the thirty-nine operations Hill had compiled, only fourteen patients survived (including the person stabbed with the scissors). In 1902 the chances were that two out of every three patients who underwent heart surgery would die. The odds were appalling. It was little wonder that most surgeons avoided operating on the heart altogether.

  It is not as if the heart is particularly complicated. The organ is divided into two separate halves with a wall along the middle.* Vesalius (see Chapter 1) had accurately describe
d the organ's anatomy in the sixteenth century, but believed blood was absorbed by the body and replaced by blood manufactured in the liver. In 1628 (almost one hundred years after Vesalius) the English physician William Harvey published his essay entitled 'The Movement of the Heart and Blood in Animals', outlining his belief that the blood circulated around the body.

  * Galen (see Chapter 1) believed this wall contained tiny holes that allowed the passage of blood from one side of the heart to the other. He was wrong, but before birth there is indeed a hole. This allows blood to bypass the lungs because they are not yet functioning. After birth this hole usually closes, although not in the case of babies born with a 'hole in the heart'.

  Harvey described how the heart is divided into two principal parts. The right side of the heart receives blood from the body and pumps it to the lungs; the left side of the heart receives blood from the lungs to pump it around the body. Each side has a smaller upper chamber called an atrium and a long, lower chamber called a ventricle.

  Blood arrives at the heart through wide main veins known as the inferior and superior vena cava. This blood, low in oxygen, enters the heart and begins to fill the right atrium – a kind of holding chamber. When the right atrium is full, the muscle contracts to help push the blood through the tricuspid valve into the right ventricle – the pumping chamber. As the right ventricle contracts, blood is pumped out to the lungs to receive oxygen. This oxygenated blood returns to the heart in the left atrium, passes through the mitral (or bicuspid) valve and is pumped away from the heart in the left ventricle. The muscle wall of the left ventricle is thicker than that of the right as much more force is needed to push the blood all the way around the body. In a normal human heart, this whole process works smoothly and rhythmically: valves open and close, blood enters and leaves, muscles contract and relax.

  The history of surgery suggests that surgeons have rarely been afraid of trying new, risky and untested procedures. By the 1900s surgeons were quite happy to cut into the body to operate on the internal organs. Appendectomies had become routine, tissue damage could be repaired and complex fractures set. Surgery was clean, relatively pain-free and generally successful. Surgeons were confident, highly respected members of society. But when it came to operating on the heart, they were terrified.

  In 1896 the famous British surgeon Sir Stephen Paget declared that heart surgery had 'reached the limits set by nature'. More sobering to most surgeons perhaps were the words of Theodor Billroth, a pioneer of surgery on the digestive system. 'Any surgeon,' he wrote, 'who would attempt an operation on the heart should lose the respect of his colleagues.' And no surgeon wanted that.

  Even twenty years later, during the First World War, surgeons would shy away from operating on the heart. Many soldiers had fragments of shrapnel left embedded in their chests, others simply bled to death. Some men survived for many years with bullets lodged in their hearts, the tissue healing around the foreign objects. Distinguished surgeon George Grey Turner summed up the situation when he was operating in a military hospital. He had the chance to remove a shell fragment, but concluded that 'it was beyond human and surgical capacity'. Even if the chances were that a patient would die without surgery, few surgeons were prepared to risk operating.

  PURPLE HEARTS

  D-Day, 6 June 1944

  * * *

  Within minutes of the first soldiers landing on the beaches of Normandy, the early casualties were on their way home. The landing craft became ambulances, shuttling backwards and forwards from the beaches to the ships. The ships went from being troop carriers to floating hospitals with makeshift wards and operating theatres. The walking wounded were patched up and returned to the beach to fight another day. As the ships wallowed in the heavy swell, the medics on board made every effort to keep the most severely injured alive. After the beaches had been taken and the Allied Army moved inland, the ships returned to England.

  The military operation to evacuate injured soldiers was as well planned as the invasion itself. While hospital ships ploughed back and forth across the Channel, teams of nurses and doctors set up field hospitals to follow the advancing troops. There were flights to repatriate the wounded, fleets of ambulances, and even special hospital trains. Back in England, while the invasion force had been gathering along the south coast, land was being commandeered for new hospitals. The generals could only guess how many casualties were going to need treatment.

  At Stowell Park, near Cirencester in Gloucestershire, the 160th United States General Army Hospital had only just been completed. Surrounded by the gently rolling Cotswold hills, lined with dry-stone walls and dotted with woodland, this was a perfect place to convalesce – it truly was England's green and pleasant land. Although the hospital was in countryside to avoid the aerial bombardment suffered by cities, it had good rail connections to London, the ports of Bristol and the south coast. An airfield had been built near by and an extensive network of concrete roads constructed across the site.

  The hospital itself consisted of row upon row of Nissen huts – long sheds made of semicircular arcs of corrugated iron on brick bases. Some huts were wards, some were offices, some were operating theatres. There were mess halls and nurses' quarters and an officers' club. There was even a parade ground, not that the patients would be doing much parading. This hospital would receive some of the most serious casualties from the war – those men who would almost certainly have died in any previous conflict. The 160th General Army Hospital was the base for the Fifteenth Thoracic Centre and a daring, confident and ambitious young surgeon: the red-haired, Harvard-trained Major Dwight Harken.

  Aged only thirty-four, Harken was held in high regard and was already shaping up to be one of the world's leading chest surgeons. By the time he came to lead the surgical team at Stowell Park, he had perfected new operations to remove cancers, and had worked alongside eminent surgeons in Boston (Massachusetts) and London before the war. He was convinced that no part of the body was off limits to surgeons – particularly the heart. What was the heart anyway but a mechanical pump? He could not understand why so many surgeons shied away from tackling heart injuries, instead allowing foreign bodies to remain lodged there – inhibiting the heart's function, dooming the soldiers to die a slow death from blood poisoning or, worse, triggering a sudden heart attack. Didn't surgeons have a duty to operate on the heart? Harken had lobbied his superiors, including the president of the Royal College of Surgeons, Grey Turner, to be allowed to carry out heart operations should the opportunity arise. Eventually, he was convincing enough to be given the go-ahead.*

  * Grey Turner accepted Harken's reasons for wishing to operate, but added one more, telling the young surgeon that he had neglected an important consideration: 'namely, the knowledge of an individual that he harbours an unwelcome visitor in the citadel of his well-being'.

  As the first casualties began to arrive at the hospital, the nurses passed along the rows of stretchers, reassuring men that they would receive the best possible care. This was true, although some of the injuries were horrific. Some men were barely able to breathe, their lungs punctured by bullets. Others were coughing up blood or had chests swelling with fluid, their insides peppered with shrapnel.

  Dwight Harken began operating around the clock, snatching sleep when he could, his energy and enthusiasm keeping him, and his team, going. Most of the operations involved opening up the chest to remove bullets, shrapnel and other debris – perhaps bits of uniform that had been in the way when the objects penetrated. It was remarkable that these men were still alive. Having entered battle at the peak of physical fitness probably saved them – that and the military effort to get them to hospital.

  Harken also had technology on his side. Penicillin was now available, anaesthetics had been improved** and blood banks had been set up to enable transfusions (during the First World War doctors were still 'letting' blood for some injuries). Antiseptic technology had also moved on. The whitewashed operating theatre was kept as clean as possible. E
veryone wore gowns and masks, and in addition to thoroughly scrubbing their hands, surgeons usually wore rubber gloves.

  ** Although in 1944 ether was still often used to induce anaesthesia, other options were now available to doctors, including injections of anaesthetic drugs. During major surgery, once the patient was 'under' a tube could be inserted directly into the trachea (windpipe) to pass air, oxygen or anaesthetic gases directly into the lungs. The mixture was controlled by the anaesthetist. Endotracheal intubation, as it is called, is still used today.

  In addition to X-rays, Harken was also able to use a new type of imaging technology called fluoroscopy. This was much like taking a live X-ray image – X-rays were projected through the patient on to a fluorescent screen. Unlike the snapshot conventional X-rays provided, fluoroscopy could show a moving image. So day after day, night after night, images were taken, objects located and chests opened up. Lungs were stitched and reinflated, and infected tissue excised. When the men recovered, Harken presented them with the fragments of metal he had removed from their bodies.

  But one day the fluoroscopic screen revealed a much more serious problem. The X-rays showed that the soldier had a bullet in his chest, but on the screen the bullet seemed to be jumping. There was only one conclusion – the bullet was lodged in the soldier's heart. With each beat, the bullet jumped. This was the chance Harken had been waiting for. He decided to operate.

  Harken had prepared well. His previous experiments on animals had shown it was definitely possible to conduct delicate surgery on the heart. With each set of operations on dogs he was getting fewer and fewer deaths. He had a closely knit team of experienced doctors and nurses who were trained for this moment but, above all, he had the overwhelming belief that they were not going to fail.

  The operating theatre took up half of a Nissen hut and it soon became very cramped. Around the operating table there were trolleys for instruments, the gas apparatus for the anaesthetic and a bulky electrocardiograph machine that drew an image of the patient's heartbeat on rolls of graph paper. Bottles of blood, matched to the patient, were brought in. As well as Harken, there were two other surgeons working as his assistants, an anaesthetist and a further surgeon to monitor the electrocardiograph. Alongside them was the scrub nurse, Shirley van Brackle. Everything was laid out ready; the young soldier was prepared for surgery and put to sleep.