BY THE TIME he assisted John Lewis at history’s first successful open heart operation, Walt Lillehei had been promoted to associate professor at the University of Minnesota. He had not only free rein with his research but a full-time resident to run his lab, Morley Cohen.
A thirty-year-old Canadian, Cohen, like so many other aspiring surgeons, had been drawn to Minneapolis by the unusual opportunities Owen Wangensteen offered. And now, what better opportunity than to work for Wangensteen’s prize pupil?
Under Lillehei’s direction, Cohen had been experimenting with ways to oxygenate blood. Inspired by the tropical fish he’d had as a kid, he was monkeying around with aquarium bubblers purchased at a neighborhood pet shop. He could oxygenate dog blood with these air stones—but getting the bubbles out after they’d done their job was difficult, perhaps impossible. After weeks of trying, Cohen was frustrated.
Lillehei showed Cohen the article from the British Journal of Surgery.
Take a look at this, said Lillehei.
Cohen agreed that the lessons of the azygos vein—the azygos factor, they called it—seemed to have great potential. The job now was to measure the flow of that tiny vessel. The Englishmen had only demonstrated its importance, not produced hard numbers that might be applied to surgery.
Cohen got to work using the same technique as the British scientists, with one addition: after tying off the superior and inferior venae cavae, the primary vessels that return the blood to the heart, he collected timed samples of the much smaller volume of blood that continued to trickle through the azygos (his collection device was a condom, which lay nicely inside the chest cavity and didn’t easily leak). Cohen used nineteen dogs, relating body weight to azygos flow. He found that an animal survived, unharmed, for thirty minutes or more with less than one tenth its normal blood flow.
Less than a tenth! It contradicted reason.
But there it was, demonstrated in research that was unimpugnable.
A brainstorm struck Cohen: Why not use a lobe of one of the dog’s own lungs to oxygenate its blood? One lobe could produce the minimal flow of blood that the azygos factor called for—and living tissue would naturally oxygenate. Using nothing but a pump, some tubing, and the lobe, Cohen proposed to bypass the dog heart—to turn the animal itself into its own heart-lung “machine.”
This was an ingenious yet simple idea, the kind Lillehei cherished. Walt told Morley to begin a new round of experiments on dogs. It was by now 1953. In a growing number of centers across America, the quest was intensifying.
If not for his machine, history might not have remembered John Gibbon. Gibbon was not an unusually fast or innovative surgeon, nor was he a universally beloved teacher. Some thought him aloof, perhaps not surprising given that he was a graduate of Princeton who’d trained in surgery at Harvard. What meager introspection he seemed to allow revealed a man of little cheer, as evidenced by a poem he wrote:
The boxes line up row on row
In and out of boxes all our lives
The womb’s a box
The coffin, too
Big concrete slabs pushing to the skies
Filled with boxes
Inside the box, softness lies here and there
To cushion our bodies in chairs and lounges
To hold our bodies in gentle sleep
As we coast down hill from cradle to the grave.
But Gibbon had his machine, long before Clarence Dennis or the many others who were building contraptions had theirs. Gibbon had started work in the 1930s, while he was at Harvard, and continued during his years as a professor of surgery at Philadelphia’s prestigious Jefferson Medical College.
Although Gibbon himself shied from publicity, his heart-lung machine experiments became a public sensation—for in the popular mind, at least, few spectacles were as beguiling as man attempting to play God with electricity and steel. Moreover, Gibbon’s work had attracted the attention of Thomas J. Watson, the chairman of IBM, an emerging power in the fledgling computer industry. The businessman provided the doctor money and technical support to help develop the heart-lung machine—which some said looked just like a computer.
“This robot, a gleaming, stainless steel cabinet as big as a piano, will soon be tested on humans,” Life magazine proclaimed in May of 1950. “It already has successfully substituted for the living heart and lungs of nine dogs for as long as 46 minutes.”
In fact, Gibbon did not try his machine on a person until almost two years later, when he operated on a dying fifteenmonth-old girl who had been diagnosed with an ASD. Gibbon opened the baby’s chest, connected her to his machine, then cut into the right atrium of her heart. The bleeding was substantial, but Gibbon could see tolerably well with the constant use of the suction. Nonetheless, he encountered a nightmare: exploring as best he could with eyes and fingers, he found no hole, nor any other abnormality inside the heart; the diagnosis of ASD had been wrong, and the baby perished. An autopsy revealed the true cause of her sickness: patent ductus arteriosus, the birth defect involving the heart’s outside anatomy that Robert Gross had first fixed in 1938—and which surgeons had routinely fixed ever since.
“This of course illustrates the importance of complete exploration of every heart which is operated on,” said Gibbon. “We might have saved this child’s life if we had closed the ductus.”
Although he was satisfied with how his machine had worked, Gibbon did not try again until May 6, 1953, when he operated on Cecelia Bavolek, an eighteen-year-old whose failing heart had sent her to the hospital three times in the last six months. Bavolek had also been diagnosed with an ASD, which is what Gibbon found when he opened her heart and deployed a steady suction that allowed him to see, if only “adequately,” as he later wrote. During the twenty-six minutes that Gibbon’s machine sustained the woman’s life, Gibbon repaired the defect.
Thirteen days later, Bavolek was discharged from the hospital, a normal young woman.
Gibbon’s success did not just overshadow John Lewis’s landmark achievement with hypothermia; it seemed that in those twenty-six minutes, the Philadelphia surgeon had captured the Grail. The only task left was duplicating his results, so that mankind, not just one lucky teenager, would benefit.
But Gibbon’s next two attempts, the following July, were disasters.
One of the patients, a five-year-old girl, was lost before Gibbon really even started: soon after he laid bare her heart, it turned blue, ballooned, and stopped beating. Gibbon forged ahead, massaging the swollen heart until its color returned, after which he connected girl to machine. Gibbon then successfully sewed up her ASD and closed the heart wall, but he could not wean her off the machine: every time he tried, her heart arrested. After some four hours, Gibbon finally gave up and disconnected the girl for good, and she died.
Gibbon’s next try was on another five-year-old girl. Hoping again to find an ASD, as diagnosed, Gibbon opened the child’s heart and did find that defect—and also two others, patent ductus arteriosus, and a hole between the lower chambers of the heart known as a VSD. Whether he could have fixed all three defects was now an academic issue, for the bleeding this time was as torrential as Clarence Dennis had encountered inside Patty Anderson, and the suction could not keep up.
“As we could not get a clear field to work in,” Gibbon wrote, “and the flow of bright red blood was so excessive, we closed the atrium and removed the cannulae.” The girl then died.
Gibbon was among the surgeons who traveled to Minneapolis two months later for one of Owen Wangensteen’s surgical symposiums.
Readers had learned of Gibbon’s one success in the May 18 edition of Time magazine, which declared that the Philadelphia surgeon had “made the dream a reality.” But even in Wangensteen’s audience, few knew about Gibbon’s July disasters. Gibbon informed his fellow surgeons at the September symposium, and they assumed he would continue on; he was, after all, the father of the movement. Yet Gibbon was so discouraged that he declared a one-year moratorium on all further human use of his machine.
In fact, Gibbon, fifty years old, would never use it again; for him, the quest had ended.
Still, Gibbon did not act humbled at the symposium. He remembered all too well how one of Wangensteen’s men, Clarence Dennis, had beaten him into the operating room with a heart-lung machine—a machine whose design could be traced to his own! And now, another young Turk from Minnesota claimed to be nearing a cardiac breakthrough.
Gibbon liked Walt Lillehei. The older surgeon had watched him deliver his first national paper at Broadmoor three years before; to an Ivy league-educated Philadelphian, the young Midwesterner with the alligator shoes and gold watch was too flashy; Lillehei seemed almost to swagger, as if, at the tender age of thirty-four, he’d already scaled tall peaks. Outside of surgery, about all Professor Gibbon had in common with Dr. Lillehei was an appreciation for fine liquor.
So when at Wangensteen’s symposium Lillehei talked about the azygos factor, Gibbon dismissed it. He didn’t care what Lillehei’s experiments purportedly showed. This 10 percent notion—what was it called again, please?—was ridiculous.
It’s just not possible, Gibbon said. Animals need much more blood.
Lillehei pulled Morley Cohen aside and said: Now I know we’re right! Gibbon doesn’t believe it!
Not long after Wangensteen’s symposium, Cohen was performing another of his “self-lung” operations on dogs, in which a lobe of a dog’s lung functioned as the dog’s own heart-lung “machine.”
By any measure, the self-lung series had been a success: of nearly fifty dogs whose hearts had now been bypassed with this method, more than 90 percent had survived. Cohen and a second resident Lillehei had brought on board—thirty-three-year-old Herbert E. Warden—had mastered the mechanics of the technique. And physiologically, the studies showed, the self-lung seemed kinder to blood than running it through an actual machine, with its many artificial components.
But no one was uncorking champagne; if anything, Lillehei and his residents were increasingly pessimistic. Unless the tubes were handled with extraordinary care, disaster loomed: one barely noticeable kink, and blood backed up into the lung, which quickly swelled and was ruined. A master surgeon might be able to avoid kinking every time, but an ordinary surgeon under all the other pressures of open heart surgery would be dangerously susceptible to error. Lillehei, Cohen, and Warden were beginning to wonder if the self-lung was too delicate a business ever to be used with patients.
On an autumn day in 1953, it happened again: a tube kinked. Cohen and Warden straightened it and continued with the operation. The dog was fine, but Cohen’s mind was elsewhere. He’d recently learned his wife was pregnant with their first child. Warden had already offered congratulations.
And that’s when Warden’s brainstorm struck: there in the attic of Millard Hall, his hands inside a mongrel dog’s chest.
Wouldn’t it be nice, said Warden, if you could plug a patient who needed an open heart operation into something like a placenta?
It would, wouldn’t it, said Cohen.
Where could they get a placenta—the organ that sends life-sustaining blood from mother to fetus?
From a second animal, of course.
But why go to the bother of a placenta? Why not just plug into an entire second animal—an animal “donor”?
Cohen and Warden were excited, as was Lillehei, who knew about doctors who had treated leukemia by connecting a patient to a donor and letting bad blood mingle with good. A search of the literature disclosed a surprising number of attempts to treat other disorders, including cancer and high blood pressure, with cross-circulation. Someone had even tried it to bypass animal hearts. All of these scientists owed a debt to the nineteenth-century French physiologist Charles Edouard Brown-Sequard, who had briefly restored eye and facial movement to the heads of decapitated dogs by injecting freshly oxygenated blood into the severed arteries of the cutoff heads.
But cross-circulation, in whatever form, had never succeeded in human use. In the fall of 1953, no one seriously believed it had a future in cardiac surgery, or anywhere.
No one but Cohen, Warden, and Lillehei, who didn’t wonder if the glass was half empty or half full, but whether it was the right vessel in the first place.
Lillehei and his residents sketched out their approach; as always, simplicity guided them.
Blood flow would have to be gentle and precise, so they needed an easygoing pump that could be calibrated. They chose a $500 Sigmamotor Model T-6S, used in the dairy industry. The Model T-6S could simultaneously move separate streams of liquid in different directions, in exactly equal amounts—almost like the human heart. It was a sturdy machine with a soft touch: it did not kick up foam, the tiny bubbles that are deadly to living tissue.
Traditional gum rubber would not do for the tubing, for it was opaque—air bubbles could hide, and a surgeon could not see that a flow was being maintained. Lillehei went to Mayon Plastics, a Minneapolis company that was run by an old high school classmate, and found what he wanted: clear beer hose, used to connect barroom taps to kegs.
And that was about it, a milk pump and beer hose.
One day in October, Warden and Cohen anesthetized two dogs. They shaved a leg of the donor dog and made small incisions to expose an artery and a vein; short, rigid tubes—cannulas—were placed in each. Then they opened the chest of the “patient” dog and placed cannulas into that dog’s appropriate artery and vein. The cannulas were tied into the beer hose, which, via the Model T-6S, connected the patient to the donor. The circuit was complete.
Calibrated to deliver the minimal flow the azygos factor called for, the pump was turned on and the patient’s heart was clamped off. For half an hour, donor dog supported patient dog. Warden and Cohen then stopped the pump, removed the tubes, sewed the dogs up, and let them both awaken.
A mistake in arranging the tubing proved to have caused brain damage in the patient dog, but the next sixteen dogs recovered without harm. Thirty minutes of potential open heart operating time, and no damage—none to the donors, either! This, this might be the Grail.
Almost as remarkable was how quickly the dogs awakened. Lillehei well remembered Clarence Dennis’s animals, across the hall there in the attic of Millard Hall: how lethargic they’d been waking up after only a few minutes on Dennis’s heart-lung machine, how it seemed the very act of blood flowing through a complicated apparatus had been damaging, through some physiological reaction as yet unknown.
Cross-circulation offered other advantages. Cleaning and sterilizing was troublesome—a machine didn’t fit into an autoclave, and chemical solutions didn’t always kill 100 percent of the germs. But beer hose was easily sanitized and, since it cost next to nothing, a clean new length could be used every time. And cleaning and sterilizing the pump wasn’t even a consideration, for no part of the T-6S came in contact with blood. The beer hose was placed behind moving metal fingers, which pushed the blood along.
Directed by Lillehei, Warden and Cohen experimented with different flow rates between donor and patient dogs. They analyzed cross-circulated blood for changes in oxygen, carbon dioxide, pH, hemoglobin, and other vital factors, and they measured blood pressure and pulse. After experimenting, they killed the animals and microscopically examined their livers, kidneys, hearts, lungs, and brains. They found no evidence that cross-circulation caused any damage.
As the autumn of 1953 progressed, Lillehei approved a second set of experiments. His assistants opened a dog’s heart and, with an ordinary laboratory cork bore, made a large hole in the wall between the lower chambers, the ventricles—a ventricular septal defect, or VSD. Then they sewed up the defect. Their purpose was less to become technically accomplished in the repair (it was only sewing) than to confirm that the low flow rate of the azygos factor provided a semidry field—that it provided visibility for the surgeon.
It did.
Lillehei and his assistants also sought to determine how the canine heart tolerated such trauma.
The heart tolerated it very well.
Lillehei was by now convinced that cross-circulation would allow him to repair a human VSD—and with experience, atrioventricular canal, tetralogy of Fallot, and other extreme defects that remained beyond the surgeon’s grasp. Just to be sure he hadn’t missed some subtle yet dangerous neurological complication, Lillehei decided first to experiment on trained animals, whose behaviors were well known and could be more reliably tested post-operatively than pound dogs or strays. Lillehei asked Paul F. Dwan, a cardiologist friend, to donate some of his purebred golden retrievers.
Son of a founder of 3M, the Minnesota Mining and Manufacturing Company, Dwan was a millionaire—but money had not brought him health. As a child, Dwan suffered from rheumatic fever, which permanently damaged the valves of his heart and left him vulnerable to pneumonia and heart failure for the rest of his life. During one of the many times he was hospitalized, Dwan, then a young pediatrician, decided to pursue cardiology—and thus became, in the 1930s, the first pediatric cardiologist in the state of Minnesota and one of the first in the world. A professor at the University of Minnesota when Lillehei met him, millionaire Dwan worked for free.
Dwan used his golden retrievers for hunting, but when Lillehei asked to experiment on some of them, the pediatric cardiologist not only agreed—he offered to have his trainer put them through their paces after they’d been subjected to cross-circulation. Lillehei accepted Dwan’s offer and found that, after cross-circulation, the purebreds performed impeccably, as usual.
Lillehei began to look for a human candidate.
When Frances Glidden learned she was pregnant, in the summer of 1952, she and her husband, Lyman, sometimes thought of their daughter LaDonnah.
Donna, as they called her, was a skinny, freckled girl whose round face and red hair evoked her father’s Irish ancestry. Donna was carefree and pretty. She liked cats and dogs and the family goat especially. If you needed Donna, the first place to look was out in back, where the Gliddens gardened and kept their many animals.
They lived in the north woods of Minnesota in a house not much bigger than a cottage. Lyman was a miner who worked the Mesabi Range, some ten miles north, in Hibbing. Over the decades, steam shovels had dug the world’s largest hole in this fabulous iron lode—a pit three miles long, one mile wide, and as deep as 435 feet. Mesabi ore, by one estimate, was the raw material for a quarter of all the steel manufactured in post-war America.
At the beginning of 1950, twelve-year-old Donna was the picture of health.
A doctor two years earlier had detected a murmur and a marginally enlarged heart, but this seemed benign: Donna played sports, did tolerably well in school, and made her First Communion. Her appetite and color were normal, and her only sicknesses were the common cold and the flu.
Then, in the spring of 1950, Donna’s energy suddenly flagged. It was if some unseen enemy had sucked the life force out of her. Her knees ached and she could not walk three blocks without becoming exhausted. She had trouble breathing; once, while in the yard, she fainted dead away. The doctors in Hibbing sent her to University Hospital in Minneapolis, where a cardiologist performed a heart catheterization—and diagnosed a ventricular septal defect, a VSD. The cardiologist could do nothing for the girl except prescribe digitalis and place her on a low-salt diet.
Donna was hospitalized in Hibbing for a week that September, but she was much better when she was discharged on Thursday, September 14. She went to bed that Friday night excited about a birthday party she was to attend that weekend. Donna shared a bed with her younger sister Shirley, one of the Gliddens’ ten children, and they often drifted off to sleep with their arms around each other. Sleep came easily that night: the weather was still summery, and a warm breeze reached the girls through an open window.
When she awoke the next morning, Shirley played in their bed with one of the kittens. She thought her sister was still asleep. Then their mother came into the room. Something about the way Donna was lying alarmed Frances Glidden.
Frances called to her husband.
Lyman touched Donna and knew immediately that she was dead.
Now, two summers later, Frances was again expecting a baby. Fall passed and it was an uncomplicated pregnancy, as LaDonnah’s had been.
Gregory Glidden was born on February 24, 1953. His color, cry, and appetite were all good. Just like his sister LaDonnah, he went home a healthy infant.
GREGORY GLIDDEN (RIGHT) WITH SIBLINGS
