St. Mary’s was part of the University of London, founded in 1845 as a teaching hospital. Prince Albert laid the foundation stone. It was an immense brick edifice, with two ranks of arched granite colonnades flanking the main entrance. The entrance itself was curious, as there was a flight of steps up to the doorway—as there were at every other entry point to the building. I thought this was odd, as anyone arriving by ambulance would have to be jostled up the steps on a stretcher.
Although I was already admitted, I had to pay a formal call on the dean of the medical school, a man named Gordon Mitchell-Heggs. Befitting someone with that sort of double-barreled name, Mitchell-Heggs was formal in the extreme. He always wore a tailed morning coat with a waistcoat and striped trousers. His shoes gleamed. Although no one warned me ahead of time, he had two tests for admission. One was whether you opened the door for his secretary when you came in. The other was whether you caught the rugby ball he suddenly threw in your direction on your way out. I did both.
Sports were an important part of life at St. Mary’s, especially rugby, which was thought to promote the kind of teamwork and selflessness that helped turn out good doctors. But it was in the field of medical research, notably immunology, that St. Mary’s had made its reputation. In 1928, a St. Mary’s researcher named Alexander Fleming discovered penicillin, revolutionizing the treatment of bacterial infections. On one of my first days, I discovered a plaque on Praed Street adjacent to the building where Fleming had worked commemorating the discovery. Later on, as a clinical student, I’d sleep nights in the room where Fleming had made his breakthrough.
I gradually accommodated myself to the clamor and cold of London, but one problem that didn’t go away was my poverty. Rhodesian bank accounts were frozen under British sanctions, and I had little money. After paying my tuition, there was almost nothing left over. I earned extra money by waiting at tables at night, wearing an old set of tails that I had inherited from my father. I tutored the children of a few well-to-do families in the neighborhood who sometimes fed me, too.
English medical school was different from the American program, where you do a four-year undergraduate degree and then enter four more years of medical training. In England medical school was five years and you entered directly out of high school. After five years you were a medical doctor. If you wanted to do surgery, however, your training then continued. At St. Mary’s we spent the first year and half of school mainly on the subjects that a premed student in America would study: chemistry, biology, anatomy. I found this crushingly boring. I was eager to begin learning medicine, impatient to be done with course work that seemed beside the point.
The exception was anatomy, which fascinated me. Gross anatomy—the dissection and close study of a human cadaver—is a long-standing medical school tradition. And it suited my aspirations to be a surgeon. Four students were assigned to a body, each of us partnered with one of the others. We started at one end of the body and finished at the other eighteen months later, carefully disassembling every muscle, ligament, bone, and organ, tracing the pathways of all the nerves and blood vessels. The bodies were embalmed in formalin, causing the anatomy room to smell vaguely of pickles. It took a while to get used to it. At the end of the day, the body was covered by a white plastic sheet, a partially disassembled former human waiting for us to resume.
In America, every medical school instructor is a professor. In England, only the head of a department is called professor. The professor of anatomy was a kind, elderly man named Frank Goldby, who didn’t say much except when delivering lectures, which he gave in a large auditorium. For some reason, Goldby always spoke directly to whoever was sitting at the end of the third row on the right-hand side. He never looked anywhere else. This was unnerving if you happened to be sitting there, and we soon learned to avoid that chair. Undeterred, Professor Goldby spoke to an empty chair day after day, until we decided to borrow a human skeleton nicknamed Fred from the dissection room. We put Fred in a lab coat and sat him at the end of the third row on the right. The entire class moved to the far side of the room, leaving Fred alone. Goldby came in, pulled out his notes, and without missing a beat delivered his lecture to the white-coated skeleton. When he finished, he said nothing, packed up his notes, and walked out as if nothing unusual had happened.
My partner in anatomy, and my closest friend, was Brian Jennings. He was a thoughtful, introspective person, smart and capable, and a bit of a renegade. I greatly enjoyed his company. Sometimes my parents would send me biltong, a dried, jerky-style game meat we used to eat in Africa. It was a rare treat for me. Brian asked to try some when I brought it for lunch one day to anatomy class. We’d been working on our cadaver for a while when I looked over and asked him how he liked the biltong. He looked at me oddly and said that it was horrible. It turned out he’d accidentally been chewing on a hunk of muscle we’d removed from the cadaver.
Brian and I sometimes put in extra study on Saturdays in the dissection room. We learned a lot in those quiet hours, a copy of Gray’s Anatomy open on the body as we took our time cutting it apart. One Saturday, there was a commotion outside. Some local toughs were heckling a few of the female medical students. Brian called down, “Do you need a hand?”
“Yes, please!” one of the women answered.
Brian tossed down a hand from the nearest body. The street gang scattered. We later returned the hand to its owner.
The seemingly endless classroom work continued. I wasn’t sure I’d made the right decision in coming to medical school. At night I’d lie awake thinking of African sunsets, when the dust in the air turned the horizon crimson. When you are near the equator, darkness comes on suddenly, without the gray twilight that lingered over soggy, gray London. In the bush you must be ready for the night, with wood gathered and a fire going before the sun is extinguished. A fire keeps lions and hyenas away and warms you under the soaring canopy of stars.
I missed my mother and Philip. I wondered what latest adventure Joni might have had. I don’t think he would have liked London, with its trackless walkways and blaring streets. School was nothing like what I’d imagined. It was an unrelenting drudgery. We had no clinical work, no exposure to patients at all in the first year. My studies seemed unrelated to caring for actual human beings. I was frustrated and unhappy.
And then I got lucky.
Surgical teams in London hospitals consisted of two senior surgeons called consultants. Consultants were always addressed as Mister, a title that commanded respect. The consultants worked with at least two junior surgeons called registrars, who were the equivalent of American resident doctors. And then there were one or two housemen—interns, as they’re called here. The whole team was called a firm and bore the names of consultants in charge.
The top firm at St. Mary’s was the one run by Felix Eastcott and J. R. Kenyon. They did complex vascular surgery, which fascinated me, and Kenyon also did kidney transplants, which at the time were still considered pioneering. One day a houseman named Hutton from the Eastcott-Kenyon firm came down to the cafeteria, where I was having lunch and studying and wondering why I didn’t just go back to Africa. Hutton happened to be from Rhodesia. He came directly over to our table and said that the firm was shorthanded that day and needed a volunteer to assist in the operating room. I don’t know if he had me in mind, but I jumped up and told him I was ready.
I had never scrubbed in before, but it felt instantly right to me. They showed me how to scrub and how to get into a gown and gloves. I was not nervous but felt excited and had to remind myself to listen closely to any instructions I got and do precisely as I was told. The operating room—they call it the operating theatre in England—was brightly lit. The walls were tiled, the floor cement. The patient, a middle-aged man, was already on the table and draped in green surgical covers. The anesthetist, a guy named Knight, was sitting at the head of the operating table, dressed in a cap and mask but not a gown. He was reading a newspaper. This, I thought to myself, was a place where I wan
ted to be. It was quiet. The outside world seemed not to exist. Whatever routine concerns you were dealing with were left behind.
I felt something else, too: a solemnness that pervaded the room. Every OR is different. Some surgeons listen to music. Some crack jokes or gossip. Some, especially in England, rage and complain and throw instruments on the floor when things go wrong. But no one is ever disrespectful of the patient, who is accorded absolute dignity and deference. Unconscious, the patient has surrendered to the skill and judgment of a surgeon, the one person in charge of everything that is to happen. I remember the moment I stepped into that world.
The surgery was an abdominal sympathectomy, an operation not commonly performed now. It’s a procedure in which a section of nerve near the spine is removed to improve blood flow to the lower extremities, the narrowed arteries often associated with diabetes or heavy smoking. The patient was on his back as Mr. Kenyon opened the abdomen. Without looking up, he told me to put my hand in and pull the intestines to one side so that he could locate the nerve. I reached into the wound and almost pulled my hand back in shock. It was warm! I’d of course had this experience gutting animals in Africa, but the only human body I’d put my hand into was a room-temperature cadaver.
From that moment on, I spent every spare moment in the operating theatre, scrubbed in and looking on, or sometimes up in the balcony watching from above. I always tried to watch Eastcott or Kenyon, whom everyone regarded as the best, but also because they were doing the kinds of pioneering surgery that most appealed to me. I also made it a point to watch St. Mary’s most legendary surgeon, a man named Arthur Dickson Wright, whenever I could.
Dickson Wright, like most of the surgeons at St. Mary’s, worked for the National Health Service (NHS), which paid for all of the hospital’s regular patients. But he also maintained a lucrative private practice in the hospital’s Lindo Wing, which was reserved for patients paying their own way. Even now, the Lindo Wing is considered among London’s finest private hospitals, and the royal family routinely delivers its babies there. Dickson Wright performed more than thirty thousand surgeries in the Lindo Wing, where he also strong-armed wealthy patients into donating to St. Mary’s.
Dickson Wright had begun his career before the discovery of antibiotics, in a time when you had to be fast and good. He was. Because he could get in and out quickly, and with minimal bruising and scarring, the risk of postoperative complications was reduced. Even though Dickson Wright had a reputation for being careless when scrubbing in, his patients almost never developed infections. And he had an uncanny ability to diagnose someone by just looking at them. His registrar would later confirm the diagnosis with whatever tests were needed, but Dickson Wright was never wrong.
When Dickson Wright turned sixty-five, he had been forced to retire from the NHS, but he continued his private practice. When I first saw him operate, he was in his early seventies. Watching Dickson Wright operate was like seeing the history of surgery playing out before your eyes. He was a throwback, the kind of surgeon that no longer existed, who performed every kind of operation. It didn’t matter if it was a brain operation or an appendectomy, Dickson Wright could do it.
After I’d become a regular observer in the St. Mary’s ORs, I discovered that I could learn a lot by watching the best—and also by seeing what could go wrong. I happened to be watching Dickson Wright on the day his career came to an abrupt end.
The patient was an older man having his prostate out, an operation Dickson Wright could probably do in his sleep. It involved opening the front of the lower abdomen. That day the anesthesiologist hadn’t shown up. Tired of waiting, Dickson Wright decided to numb the man himself by administering an epidural at the base of his spine. He ordered the patient to roll over, stuck him, and then waited briefly before slicing him open.
Either the epidural was misplaced or perhaps Dickson Wright had been impatient, but as he made the incision the man began to writhe and moan in pain. The man’s agony increased as Dickson Wright went on. After a few minutes, he yelled at the patient.
“Hold still!” he said. “You’re not helping me at all.”
Somehow the operation was completed and the traumatized patient was wheeled away to recover. The nurses from the OR, horrified at what they’d seen, reported it to the hospital’s administration. And that was the end of Dickson Wright, one of the best surgeons I ever saw, until he wasn’t.
I was most interested in the heart. It’s a remarkable organ. A pump made of muscle, consisting of four chambers and four valves, it beats about every second, day after day, year after year, for decades. Sometimes people are born with congenital defects in their hearts or acquire them as a result of some disease. Many others develop heart failure as a consequence of narrowing or blocked blood vessels that elevate blood pressure and overtax the heart—or suffer heart attacks when blood flow to the heart itself is interrupted. But as modern surgical techniques were developed to correct problems in every other organ of the body, the heart was left out. Unlike the other organs, the heart moves, a seemingly insurmountable barrier to operating on it. And if the heart stops, the patient dies. The heart is the body’s on-off switch. No one dared touch it.
In 1896, a German surgeon repaired a stab wound to a man’s heart, sewing it up as the heart beat on. The patient survived. And for the next half century, nobody tried anything like it again, though there had been some halting progress. During the Second World War, a US Army physician named Dwight Harken successfully operated on more than a hundred soldiers with severe chest wounds, including thirteen surgeries in which he removed shrapnel or bullets from inside the heart while the heart beat on and blood gushed from the incision. There were also a handful of risky repairs to defective valves, including an operation in which the surgeon used his finger instead of a knife to open up a narrowed valve. But the main problem remained: there was no way to safely stop the heart and work on it.
In the fall of 1952, a five-year old girl named Jacqueline Johnson was brought to the University of Minnesota Hospital in the States with a suspected hole in the entrance chamber of her heart. She was just my age at the time. She weighed less than thirty pounds and would surely die unless the hole could be closed. Dr. F. John Lewis, accustomed to the frigid cold of Minnesota—and perhaps aware that children sometimes survived near drownings when they fell through the ice in winter—decided to risk putting Johnson into a state of hypothermia and then stopping her heart long enough to sew up the hole. The theory—which had been tested on animals in the lab but never tried on a human—was that the cold would extend the time the brain could go without blood and be undamaged.
On September 2, 1952, with Johnson on the operating table in a shallow trough, Lewis administered the anesthesia himself, a mix of pentothal and curare. Johnson was then packed in ice, and her temperature began to fall. It took more than two hours for it to reach 28 degrees Centigrade—about 82.4 degrees Fahrenheit. Her heart rate, which had been speeding along at 120 beats per minute, fell below sixty. Lewis opened her chest and clamped off the heart, noting the time. Brain cells begin to die after four minutes without oxygen. How much longer hypothermia might extend that window was uncertain. Lewis made an incision in the right atrium and quickly found the hole. He sewed it shut as the clock reached four minutes. But it leaked. Lewis put in another stitch and it held. Five minutes had gone by.
Lewis closed the incision in the heart and removed the clamps. He began massaging the heart, which gradually returned to a normal rhythm. The chest was closed, and the ice was replaced with warm water. Eleven days later, Johnson went home, the first person in the world to have undergone open-heart surgery. Even though Jacqueline and I then lived on opposite sides of the earth, our paths would cross one day.
It was the beginning of a new age in surgery. The heart was no longer untouchable. But the risks of open-heart surgery remained staggering. After the Johnson case, Lewis operated on two more children with heart defects, using his hypothermia technique. Both died. Lew
is stopped doing heart surgery and moved to Northwestern University. He retired to California at the age of sixty and wrote a caustic book, So Your Doctor Recommended Surgery.
One of the surgeons assisting Lewis when he operated on Jacqueline Johnson was his best friend, C. Walton Lillehei. After Lewis abandoned open-heart surgery under hypothermia, Walt Lillehei was determined to find a better technique. The ultimate goal was some sort of “bypass” machine that could circulate oxygenated blood through the body. This would allow the heart to be completely stopped and worked on not for a few minutes, but perhaps for hours. Experimental designs for a “heart-lung” machine had been tested as far back as the 1930s. None worked at first, but in March 1953 a surgeon named John Gibbon at Jefferson Hospital in Philadelphia repaired a simple hole in the heart of an eighteen-year-old woman named Cecelia Bavolek while she was attached to a primitive heart-lung machine. Gibbon had tried the machine once before, but that patient died. This time it worked, even though the blood clotted and foamed as it passed through the machine’s oxygenator. But Gibbon’s next five patients after Bavolek all died. He never used his machine again and quit heart surgery.
At the University of Minnesota, one of Lillehei’s residents had a pregnant wife. One day he remarked to Lillehei that the fetus was being kept alive by a kind of natural heart-lung machine—the placenta—and that it might be possible to connect a child with a heart defect to a parent in order to make a surgical repair. It was a ghastly idea, but Lillehei was intrigued. After trying the procedure on dogs in the laboratory—Lillehei used a pump from a milking machine to move blood between the animals—he decided to try it on a human.
When word got around the hospital about the procedure, there was a chorus of objections. Nobody thought it was a good idea. As one staff cardiologist put it, Lillehei was likely to kill both parent and child and go down in history as the only surgeon to ever have a 200 percent mortality rate in a single operation. But Lillehei was undeterred, and on March 25, 1954, two people scheduled for surgery were wheeled into the OR.
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