Blood and Guts (12 page)

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. Everyone 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.

Opening the chest is never something surgeons attempt lightly.
There is so much that could go wrong. Soon though, Harken has
made a foot-long incision and pulled apart the ribs with a retractor
to expose the beating heart. It is obvious that there is a large fragment
of foreign material in the right ventricle. Harken places
sutures around the site, ready to be sewn together, then he cuts a
small hole in the outer layer of muscle. Blood sprays out but the
heart keeps beating. Can he stem the massive bleeding before the
patient loses too much blood? And can he avoid the heart going
into ventricular fibrillation – when the muscle loses its natural
rhythm and beats uncontrollably?

Harken's hands are working in a well of blood; everything is
bright red. He clamps his forceps firmly over the shrapnel and pulls.
It sticks. The fragment of metal is plugging the hole he has cut. The
bleeding stops; the heart keeps beating. Then suddenly, like the pop
of a champagne cork, the object bursts out of the hole and so does
the blood. It gushes in a torrent, a massive haemorrhage. The heart
keeps beating, but time is running out. Harken has only seconds to
close the hole before blood loss becomes too great. The patient's
blood pressure drops but Harken doesn't panic.

As his assistant grasps the sutures in an attempt to tie them
together, Harken flings the clamp and shrapnel across the room,
narrowly missing Shirley the nurse. He makes another attempt to tie
off the sutures, but nothing seems to stop the disastrous flow of
blood. In desperation, Harken sticks his finger in the hole. The
haemorrhaging stops, the heart keeps beating.

With his finger still in the hole, Harken begins to sew around it
– underneath the finger and out the other side, gradually pulling
the two sides of the gap together. One of the other surgeons jokes
later that it would have been easier to cut Harken's finger off and
leave it there, embedded in the heart wall. Harken slowly removes
his finger as the sutures are tightened, but when he tries to pull his
hand free, it will not come. He realizes he has sewn his glove to the
heart wall. With the glove cut free, the blood pressure starts to rise.
The soldier makes a complete recovery and Dwight Harken
becomes the first surgeon to successfully cut into a beating heart.
He is the first true cardiac surgeon.

Soon Harken would perform the operation again, and again,
building up an impressive collection of trophies – shrapnel, bullets,
fragments of clothing – all removed from soldiers' hearts. In the
end he would operate on a total of 134 patients. There were no
deaths. News of the remarkable surgery being undertaken at the
160th General Army Hospital soon spread. Everyone wanted to meet
this dynamic young surgeon. There were visits from leading
surgeons, generals, the Duchess of Kent, Queen Elizabeth (the
future Queen Mother) and even Glenn Miller and his band, who
played a few numbers in some of the wards. One of Harken's operations
was made into a movie. As he worked, a Hollywood cameraman
lay above the table on some makeshift scaffolding to capture the
surgery in all its gory detail.

As the operations progressed, Harken gradually came to perfect
his technique. New procedures were suggested and tried. At one
point it was thought that an electromagnet might be useful to
extract the metal fragments. It certainly seemed like a good idea, so
a giant electromagnet duly arrived and was suspended over the
operating table by a crane arrangement. Unfortunately, the implications
of bringing a giant magnet into an operating theatre had not
been fully thought through. When the switch was thrown and the
magnet energized, the lights dimmed, the electrocardiograph went
crazy and every metal surgical instrument in the operating theatre
flew at high velocity towards it. Fortunately, there were no injuries
but the idea was abandoned.

One of the surgeons who visited Harken was impressed by an
operation, but questioned how much use this pioneering surgery
would have after the war. What help would it be in peacetime to
know how to remove bullets from a soldier's heart? But this visitor
missed the point. Harken had done far more than perfect the
removal of shrapnel. He had proved that it was possible to cut into
a beating heart without killing the patient. The heart was no longer
untouchable; it could be operated on safely and successfully.

Before the war intervened, Harken's ambition had been to
operate on patients suffering from mitral stenosis. This disease
affects the mitral valve, which controls the flow of blood between
the left atrium and left ventricle. Mitral stenosis was usually the
result of rheumatic fever and caused a narrowing in the opening
of the valve. Sufferers from mitral stenosis endured all the usual
problems of a weak heart, including poor circulation and breathlessness.
The condition could leave them completely incapacitated
and virtually guaranteed an early death. A couple of surgeons had
attempted to cure the condition in the 1920s, leaving a succession
of patients dead on the operating table. With his wartime experience
behind him, Harken was ideally positioned to try again, and
other surgeons had the same idea.

In 1948 Harken became one of four surgeons to successfully
operate on heart valves.
^*
Having proved that cutting into the heart
was possible and survivable, the technique was relatively simple. The
surgeons would make a small incision in the heart wall before inserting
a tiny knife, scissors, or simply their finger to reopen the heart
valve. They could not see the area they were operating on and had
to feel what they were doing. All this would take place in a pool of
blood while the heart was still beating.

^*
The first of these operations was carried out by Charles Bailey in Philadelphia. Harken
carried out his first operation a few days later, but was the first to publish his results.

It was known as 'closed-heart' surgery, although 'smash and
grab' heart surgery would have been equally appropriate. As
surgeons perfected their techniques, the procedure gradually
became safer. Nevertheless, if there were any unforeseen complications,
or a new experimental operation went wrong, the patient
would usually die. And many patients did. Not only were the
surgeons operating blind, they were also operating against the
clock. With a hole cut into the heart, blood loss was tremendous.
Although blood transfusions were used, surgeons had only around
four minutes between cutting into the heart and sewing the hole
closed before a fatal amount of blood was lost. Making anything
other than a small hole in the heart would cause massive bleeding,
and death would be virtually instantaneous. To attempt anything
more ambitious, surgeons needed to see what they were doing and,
above all, they needed more time.

Canadian prairie, near Toronto, 1951

Dr John McBirnie was having a miserable day. The prairie was
bitterly cold, he was wet and up to his knees in dirt. Despite the fact
that every farmer had told him there were groundhogs 'every-bloody-where'
and they were a 'bloody menace', he had not seen a
single one of the vicious bastards all day.

McBirnie didn't know what he was doing wrong. He had come
well prepared for the role of chief groundhog catcher: he set off
every morning dressed in waders and armed with a shovel, but his
results were pathetic. He had tried digging them out and flushing
them out with water. He had sat by their burrows; he had stamped
up and down. Frankly, he was running out of ideas.