The Rise and Fall of Modern Medicine (16 page)

Following Gibbon's misfortunes at the operating table

Thus the position in 1954 was simple. Either another way must be found to use the oxygenator without killing the patient, or cardiac surgery had reached the end of the road.

The scene now shifted to Minnesota in the middle of the American plains, where Walton Lillehei at the University of Minneapolis and John Kirklin at the Mayo Clinic in Rochester would between them initiate the modern era of open-heart surgery. Within two years of Gibbon's disasters, they had both, with the help of the pump, successfully operated on children with Fallot's. The bridge between Gibbon's experience in 1953 and the rebirth of open-heart surgery had, paradoxically,
nothing to do with the pump at all but rather the success of forty-five operations carried out by Walton Lillehei with the help of ‘cross circulation', where the patient's blood was passed not through an oxygenator but through a human volunteer. The beauty of cross circulation was that it dispensed with artificial forms of oxygenation of the blood in favour of the most natural and physiological substitute, the lungs of a volunteer. In retrospect it now seems an obvious, not to say ideal, solution, but it was not purposefully planned, emerging instead during an experiment on dogs, during which ‘the chance remark was made that it would be very nice if a placenta was available for patients who were in need of open-heart surgery'. (The concept of a ‘placenta' refers to the situation where the foetus receives its oxygen from its mother's circulation.) When this new idea was experimentally tried out in dogs by linking together their two circulations, the results were exceptionally good. Not only did they survive but both the dogs operated on and the cross-circulation ‘donors' were noted to be up and about within a couple of days.
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Lillehei started using cross circulation for open-heart surgery in children on 13 August 1954, when he performed the first open-heart repair of a boy with Fallot's, thus initiating the third step in the evolution of the surgical treatment of this condition. There was no shortage of human volunteers to act as the cross-circulation partner and a 29-year-old man from the child's home town played the crucial role:

From this auspicious start, Lillehei went on to perform nine further Fallot repairs – four of whom survived – as well as thirty-five other operations involving several types of complex congenital heart abnormalities. This technique of cross circulation, Lillehei later maintained, was the major force to start heart surgery moving again. ‘The unprecedented success of the cross-circulation technique in patients with complex defects, and often intractable heart failure, played a crucial role in rapidly dispelling (virtually overnight) the widespread pessimism that had prevailed at that time amongst cardiologists and surgeons concerning the feasibility of open-heart surgery in man.'
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It was obvious, however, that the future could not lie with cross circulation, not least because it exposed the healthy donor to an unacceptable risk (although in fact there had been only one serious complication, where the donor had had to be resuscitated). There was thus no alternative other than to return to the pump, and here Lillehei and Kirklin took separate routes. Kirklin thought the principle behind Gibbon's pump to be essentially sound and persuaded the Mayo Clinic to invest heavily in modifying and improving it. In the summer of 1954, Lillehei encouraged a young research worker in his department, Richard DeWall, to resurrect an old idea where oxygen was bubbled into the patient's blood in a reservoir outside the body and then ‘debubbled' before being returned.
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The psychological barrier of open-heart operations had now been broken. Equipped with their pumps, Kirklin and Lillehei
dominated cardiac surgery for the next ten years. True to form, their initial experiences were disastrous. All of Kirklin's first five patients died either during or immediately after the operation. Nonetheless, there was a sense that if they persisted it would ‘come right', and it did. The mortality rate fell rapidly to 50 per cent for the next ten patients, and then to 30 per cent, and within a couple of years it had fallen to single figures.

It is necessary to appreciate just how ill these children were. Nowadays babies born with Fallot's are operated on in the first year of life so one no longer sees what Kirklin called the ‘pitiful' state of those he operated on. It is well illustrated by one of Lillehei's early cases, a seven-year-old girl whose twin sister had a normal heart. She weighed only 36 pounds compared to her sister's 56 pounds and her cyanosis – the blue tinge of the skin – was ‘intense'. She was ‘undeveloped and undernourished' and had recently started having convulsive seizures caused by inadequate oxygenation of the brain. Following her operation ‘her immediate colour change from intensely cyanotic to pink was dramatic', and by the time she came to leave hospital her clinical appearance was described as ‘normal'.

It is difficult to imagine how impressive such results must have appeared at the time and, more astonishingly, how consistently they were achieved. In Kirklin's account of his first seventy operations there is a table listing their subsequent medical conditions. With only very few exceptions it reads: ‘Asymptomatic, full activity.'
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Soon the repair of Fallot's Tetralogy became routine, and Kirklin and Lillehei turned their attention to even more complex abnormalities such as repositioning the major arteries as they emerge from the heart. Kirklin subsequently recalled the atmosphere of those days:

By 1960 they had operated on every single ‘operable' heart defect in children and turned their attention to replacing diseased valves in adults. Technically these are staggeringly difficult operations, requiring patients to be on bypass for several hours, as the diseased valve has first to be carefully dissected out and the new one sewn into place with hundreds of separate stitches. The results followed precisely the same pattern as the operations in children, with initially a very high death rate of around 90 per cent, either from the operation itself or the failure of the artificial valve to function, as they tore easily and sometimes broke.
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Donald Longmore, of London's National Heart Hospital, describes the results of these early operations as ‘horrendous': ‘The commonest post-operative complication was severe multi-organ damage. Moderate cerebral impairment [i.e. brain damage] was for a time almost routine, with cerebral devastation [irreversible brain damage] a frequent occurrence often associated with kidney failure.'
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No sooner had surgeons resolved those problems associated with valve replacement than some were turning their minds to
what is often considered the ‘ultimate operation', the heart transplant, which was performed for the first time by Christiaan Barnard in 1967.
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This looked as if it might be cardiac surgery's armageddon, for in the following year 100 transplants were performed across the world and not a single patient survived. In response to these catastrophic results, a moratorium was imposed on further heart transplants, with only one surgeon, Norman Shumway of Stamford University, carrying on in the face of bitter opposition. But within ten years this too had ‘come right'. By the early 1980s 2,000 patients a year in the United States were receiving a heart transplant, with a survival rate of over 80 per cent.

And for all this, ultimately, Gibbon must take the credit. Before his pump, cardiac surgery was essentially limited to one crude ‘blind' operation – the dilation of narrowed valves. From 1955 onwards and with increasing competence the surgeons were able to do dozens of different complicated procedures which, by the 1980s, were benefiting tens of thousands of patients every year. No doubt if it had not been Gibbon it might have been someone else, and it is certainly true that there were others involved in building pumps in the late 1940s, notably Viking Bjork in Sweden and Donald Melrose in London. But Gibbon was the first. The challenge he set himself in the 1930s, before he could have imagined what it might lead to, now seems breathtaking. It would be difficult enough to build a pump nowadays from scratch, let alone at a time before the advent of appropriate materials such as plastic and with only derisory funds for medical research. Further, Gibbon and his wife were not only alone, but for the best part of twenty years had to contend with the scepticism, indeed active discouragement, of their professional colleagues, who had no faith that their pump would ever be put to practical use.

T
he range of surgery in the post-war years expanded prodigiously with the introduction of ‘mass' operations, performed in their tens of thousands for the alleviation of the ‘chronic degenerative diseases of ageing', an ugly term to describe what happens when the tissues of the body are no longer able to renew themselves, so that the lens becomes cloudy with cataracts, or the surfaces of the joints become cracked. These forms of chronic degeneration are important because they diminish function in a way that seriously impairs the quality of life. The obvious solution is some form of ‘spare-part' surgery where a clouded lens or diseased joint is replaced with an artificial part made of some robust material. But there was a catch. ‘Mass' problems require ‘mass' solutions, which require that the technical problems involved in such operations be resolved in such a way that they become straightforward and the results reliable.

These ‘mass' operations represented the ‘paradigm shift' as it applied to surgery, where the historical preoccupation with infectious disease gave way to a preoccupation with age-related chronic disease. Historically, most of the workload of orthopaedic surgeons had involved trying to
correct the consequences of chronic infections (such as tuberculosis) of the bones and joints, or the skeletal abnormalities associated with polio. By the early 1960s both problems were fast disappearing and indeed there was much speculation that orthopaedic surgeons might soon become an endangered species, until these new ‘mass' operations of replacing arthritic joints arrived just in time to save them. Now they have more than enough to be going on with. These operations are so common – 40,000 hip replacements are performed in Britain each year – as to have become routine, but their development required just as much determination – and luck – as any of the other definitive moments.
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There is no better illustration of these matters than the career of John Charnley and the events that led to his singular achievement – the total hip replacement.

John Charnley's hip replacement is, by definition, a successful operation. It is straightforward (the skills can be readily acquired as part of general orthopaedic training), it works, and it lasts. From this one might readily surmise that it is also ‘simple', but that would be misleading. Certainly the principle appears simple enough – cut away the arthritic hip and replace it with an artificial ball and socket – but ‘the mechanics of the hip joint are so complicated that a satisfying conception is scarcely obtainable'. This complexity arises because the hip joint has to fulfil the apparently incompatible tasks of both sustaining the weight of the body while at the same time being fully mobile.
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Even if the challenge of replicating the remarkable mechanical properties of the hip can be overcome, the problem remains of how to implant it in such a way that it lasts as, not surprisingly, the body does not take kindly to having chunks of metal and plastic inserted into it.

The underlying problem in arthritis of the hip is the erosion with time of the cartilage that covers both the head of the femur and the cup (or acetabulum) into which it fits in the pelvis, thus
exposing the bone underneath. So, instead of two glistening surfaces rolling over each other, bone grinds on bone. The result is a constant and nagging pain much like a toothache, which is often worse at night, making sleeping difficult or impossible, and those with hip arthritis are often described as appearing tired or having a haggard expression. If, as often happens, the arthritis affects both hips, then this alters the biomechanics of the skeleton so the pain radiates up into the lumbar region and down to the knees. Then there is stiffness because, with a painful joint, the surrounding muscle groups go into spasm to limit its movement. The combination of pain and stiffness necessarily limits mobility which, depending on severity, may range from ‘the patient is bedridden and can walk only a few yards with stick or crutches' to ‘walking limited to less than one hour with a stick'. Arthritis of the hip drags a person down and so destroys the zest for living as to make some suicidal.
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