A Short History Of Heart Surgery

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IN MAY OF 1975, when I was fortyseven, I developed angina (heart pain due to an insufficient supply of blood to the heart muscle), and about two months later, after a stress test, a coronary angiogram, and various blood tests, I underwent an operation. The operation was a coronary artery bypass in which veins from my leg were used to bypass the obstructed arteries of my heart. For about one hour, while this was being done, my heart was stopped and a heart-lung machine did the work of pumping and oxygenating my blood, work ordinarily performed by rny heart and lungs.

In the eight years that have passed since my operation, I have lived a full life, practicing surgery, writing, playing tennis and racquetball, and, in general, enjoying myself. I have not once had an attack of angina.

I am a very lucky man. If I had been born twenty-five years earlier, if I had been forty-seven in 1950 and developed angina then, I would probably not have lived more than a couple of years; and if I had, I could have done so only by greatly restricting my activity. In 1950 there were no stress tests, no angiograms, no heart-lung machines, and, of course, no open-heart surgery, which has existed for barely thirty years. When we realize that in 1983 there will be about eighty thousand coronary by-passes performed, and that thousands of other hearts will be opened so that congenital anomalies can be repaired and new valves inserted to replace worn-out or diseased valves, we begin to appreciate how rapidly heart surgery has progressed in a very short time.

 

Hippocrates, who was born in 460 B.C. and is regarded as the father of medicine, wrote, “A wound in the heart is mortal”; with few exceptions the heart remained sacred territory, outside the bounds of surgery, for centuries. Theodor Billroth, the famous Viennese surgeon who first successfully removed a stomach cancer and who devised the operation still in general use for partial stomach removal for ulcer or cancer, wrote in the 1880s, “Any surgeon who wishes to preserve the respect of his colleagues would never attempt to suture the heart.” When a man of Billroth’s eminence spoke, surgeons listened; in fact, it’s probably safe to say that Billroth’s writings delayed the development of heart surgery for many years.

But not, as we know, indefinitely. Surgeons are generally adventurous people, and when confronted by acute problems, insoluble by medical means, they will at least consider a surgical approach. Knife and bullet wounds of the heart fall into that category, and by 1909, despite Billroth’s edict, 109 cases of suturing of wounds of the heart had appeared in the surgical literature. True, 60 percent of these patients died, most of them because of infection, but without suturing the mortality would have approached 100 percent. Still, the British surgeon Stephen Paget, who knew of some of these successful cases, wrote in 1895, “Surgery of the heart has reached the limits set by Nature to all surgery; no new method and no new discovery, can overcome the natural difficulties that attend a wound of the heart.”

 

As is true of most advances in surgery, progress in heart operations was related to developments in other fields. For example, it was 1846 when William Morton, a medical student and one-time dentist, first demonstrated the use of ether as an anesthetic (in the famous “ether dome” of Massachusetts General Hospital); in 1895 Wilhelm Roentgen discovered the X ray; and in 1901 Karl Landsteiner discovered blood typing, which eventually made transfusions safe and practical. These three advances, once they had been refined and accepted, all contributed significantly to the advance of heart surgery—as, of course, did Alexander Fleming’s discovery of penicillin in 1928.

From 1912 on, sporadic attempts were made at elective surgical repair of heart problems. On May 20, 1923, for example, Elliott Cutler, professor of surgery at Harvard, operated on an eleven-year-old girl who was totally bedridden, constantly coughing up blood, all because the mitral valve of her heart, the valve that separates the left atrium (the chamber that collects blood from the lungs) from the left ventricle (the chamber that pumps blood out to all the organs of the body except the lungs), had been damaged by rheumatic fever. The girl had mitral stenosis, a condition usually caused by rheumatic fever and one that was extremely common until the advent of penicillin (which enabled doctors to prevent rheumatic fever by promptly treating streptococcal infections).

Cutler operated on her beating heart by inserting a sharp instrument through the wall of her heart until it had, in his estimation, reached the mitral valve, which he then cut, blindly of course.

His little patient lived, in improved health, for four and a half more years. But the next six patients on whom Cutler operated died, and, discouraged, he gave up on the operation.