From the Winter 1997 Issue, Volume Six, Number One:
Somme casualties being evacuated from Charing Cross Station
by J. Hodgson Lobley
War and the First Century of Heart Surgery
By Alan S. Coulson, MD, PhD, FACS and Michael E. Hanlon, Research Editor
In July 1896, Stephen Paget's classic textbook, SURGERY OF THE CHEST, was published. In this book, he declared the heart to be off-limits to surgeons. He wrote, "Surgery of the heart has probably reached the limits set by nature, no new methods and no new discovery can overcome the natural difficulties that attend a wound of the heart." On the Continent, Professor Billroth concurred: " A surgeon who tries to suture a heart wound deserves to lose the esteem of his colleagues." Paget and Billroth's pessimism not withstanding, Ludwig Rehn of Frankfurt - a former German hussar turned surgeon -- made the first successful suture of a human heart wound in September of the same year, 1896. This was the beginning of cardiac surgery -- exactly one century ago. That same period would see the two costliest wars in history fought. As human tragedies, they were unsurpassable; but as for medicine, especially the new field of heart surgery, they were a boon.
Less than 20 years of Paget and Billroth's cautions and Rehn's procedure, World War I began. With ill-informed commanders repeatedly relearning that bravery was no match for machine guns fired over open sites, there were unprecedented scenes of horror in the casualty-clearing stations. It is difficult to imagine the carnage. Men were driven insane by the sight and sound of it.
Most soldiers with heart wounds die on the battlefield. They perish from the immediate trauma, from shock -- the failure of the cardiovascular system to deliver sufficient blood flow --, or from the accumulation of blood in the pericardium. According to the British Official Medical History one typical Great War casualty clearing station saw only one patient among 123 with chest wounds who had survived with a missile in his heart. [Note 1.] But, even though this phenomena was a statistical rarity, the blood-letting on the Great War's battlefields produced a substantial number of patients with bullets and metallic fragments in their hearts who survived their initial injury. These wounded survivors demanded some attention because their prospects were still dismal:
"The practical significance of the retained foreign body is twofold, in the early stages as a cause of infection usually giving rise to pericarditis, in one of the cases recorded to an abscess in the wall of the ventricle; in the later stages as causing disturbances of the heart's action. It is noteworthy that in one of Sir Berkeley Moynihan's cases an abscess in connection with an obsolete infection was met with as late as two month after the entry of the missile." [Note 2.]
Although it was still thought by the medical establishment that nothing could be done, before its conclusion, World War I would forever change the attitude of physicians towards heart surgery. Dedicated and resolute surgeons working under desperate circumstances bucked conventional medical wisdom and found new ways to work successfully on or near the heart. The British Official History tersely describes the post-war shift in attitudes:
The feature of the surgery of the war as regards wounds of the heart is therefore a familiarity with conditions which were previously rare, and the evidence which is afforded that the treatment of injuries to heart has now become a definite and promising field for the surgeon. [Note 3.]
But how did this shift in attitudes come about? Once again the British Official History is instructive. It gives some excellent examples of the development of new procedures to drain the Pericardium, three new methods for repairing wounds to the heart and techniques for removing foreign bodies in it. [Note 4.]
A case study from the new methodology for repairing heart wounds demonstrates how progress was made in an ad hoc fashion. The Victoria Cross is the highest British award for bravery in the face of the enemy. Regimental surgeons were awarded Victoria Crosses on three occasions during the 1916 Battle of the Somme as many of them went into no man's land in close support of their men. In our opinion, some type of medal should also have gone to the English surgeon, Mr. George Grey Turner [British surgeons are addressed as "Mr." rather than "Dr."]. He made one of the earliest attempts to remove a bullet from a soldier's heart in the following spring after the Battle of Cambrai at a British base hospital. While the bullet was never removed, Grey Turner's surgical team saved the patient's life and advanced cardiac surgery.
Fired from 500 yards, a machine gun bullet went through the victim's left breast pocket of his tunic and through the left nipple into the heart. On x-rays, the surgeons could see the tip of the bullet moving around in the left ventricle. With no blood bank, no antibiotics, with just primitive ether anesthesia and poor lighting, Mr. Turner exposed the heart through the left chest. The spot where the bullet had entered the heart was marked by a depression surrounded by a roughened, whitish area.
At first, he could not find the bullet, even after probing with a needle. Finally, in desperation, he rotated the heart and palpated it; he could feel the bullet right in the middle of the heart, lodged in the septum. At that point, the surgical team got a fright because the heart totally stopped beating (pacemakers had not been invented yet). Somehow, they got the heart restarted and what happened next during the hour and three-quarter procedure was described in the BRITISH MEDICAL JOURNAL in a 1940 article:
"...the pericardium was sutured, a small drainage-tube being left in the lowest part of the sac and another laid along the outside near the suture line. The flap of chest was replaced and held in position with catgut sutures...the drains being brought through the centre of the lower oblique incision." [Note 5.]
After the Great War, Grey Turner had a distinguished career as a surgical innovator developing new procedures for abdominal and esophageal cancer. The soldier he had operated on in 1917 subsequently lived through 1940 when Mr. Turner reported the case. The soldier was quite well; just a little tired at times - more from his home front work for the Second World War than his wounds from the First!
During the inter-war years minor advances were made in France and the U.S. on opening up the mitral valve, but progress in heart surgery slowed. Peacetime had reduced the numbers of the most challenging kind of cardiac patient -- those with missiles like shrapnel, bullets and splinters lodged in the heart. The individuals with such difficulties suffered a high mortality rate from operations, so foreign bodies were not regularly removed simply because of their presence. Unfortunately however, even without discomfort or other symptoms, patients with fragments left in their hearts had up to a 25 percent chance of dying of infection or other complications. Another war, however, was coming and, by greatly expanding the number of casualties with wounds to the heart, would challenge the practitioners of cardiac surgery to greater innovations.
Traumatic shock was still a tremendous problem on both World War II battlefields and in surgical suites. Steven Johnson tells how a group of Thoracic surgeons at New York's Bellevue Hospital responded:
"[A] grant was approved and the Bellevue group began to study the physiologic mechanisms and treatment of shock. They found that a 40 to 50 percent loss of blood volume caused a profound reduction in cardiac output, venous return, and a peripheral blood flow. To replace this blood loss, whole blood was more effective than plasma, a finding demonstrated again and again on the battlefields. Their work...was described in forty-nine reports to the Committee on Medical Research and the Office of Scientific and Research Development and in several reports to medical journals.
Johnson goes on to discuss other results from this study that benefited heart surgery:
"The Bellevue shock study was [also] a milestone in the evolution of cardiac catheterization. It demonstrated that cardiac catheterization was a safe procedure that yielded much useful physiologic and clinical information...
[Another] important advance made during the war years in the field of cardiac catheterization was the development of accurate methods of measuring intracardiac pressure," [Note 6.]
But as in the First World War, the greatest breakthroughs came from dealing with the flood of casualties from the war's battlefields. July 1946 marks the date of a series of important publications by the U.S. surgeon, Dr. Dwight Harken. At the start of the Second World War surgeons had continued the conservative approach of not removing missiles from the hearts of patients who had survived the original trauma and were in a non-emergency state. Later, though, special thoracic surgery hospitals were established to treat casualties from D-Day. Dr. Harken was director of the Fifteenth Thoracic Center based at Cirencester in England and he knew that, if bullets or shell fragments were left in or near the heart, many patients would still die of sepsis or embolism. Harken and his team set out to remove as many missiles as possible using a variety of the latest surgical techniques:
"...Prior to operation, the position of the missile was pinpointed by fluoroscopy. At operation, the patient was induced by intravenous pentothal sodium anesthesia; intubated with a large-bore endotracheal tube; and maintained with nitrous oxide, ether, oxygen, and assisted respiration. To remove the missile, the heart was often split wide open, with tremendous blood loss. Rapid, massive, blood transfusions were needed to keep the patient alive. Whole blood was often administered, under pressure, at rates up to one and one-half liters per minute. Penicillin, which was just beginning to make an impact on thoracic surgery, was often given in 10,000 unit injections..." [Note 7.]
As a result, in the 10 months after D-Day, 134 operations were done to remove retained shell particles in and around the heart. Remarkably, Dr. Harken reported that there were no deaths among these patients. His wartime results inspired other surgeons to rethink surgical approaches to the heart. Following this pioneering boost to heart surgery, surgeons in peace time practice were encouraged to try to open up diseased mitral and pulmonary valves in the heart. In this way, with support from military medicine, heart surgery was truly established by the late 1940s. Many advances have been made since Grey Turner's heroic effort in the First World War. Dr. Harken's methods from the 15th Thoracic Center have been further improved upon, surgical suites are better illuminated, specially trained thoracic nurses help recover patients, and surgeons have the instruments designed by brilliant British surgeon and war-time consultant, Mr. Tudor Edwards. Most important, today's patients have blood banks and they are able to receive blood under pressure at the rate of six pints in a minute.
It took fifty years for surgeons to prove that Dr. Paget was wrong about operating on the heart and that the former soldier, Ludwig Rehn, had been on the right side of medical history. A large part of this was due to the pioneering efforts of war surgeons working under desperate circumstances. They brought about revolutionary changes in the approach to the heart. This was possibly one of the very few good things to come out of the suicidal conflicts that engulfed the world. We still have a tremendous debt to Mr. Turner, Dr. Harken and their colleagues.
Ibid.; pp 461.
Ibid.; pp 442.
Ibid.; pp 462-5.
BRITISH MEDICAL JOURNAL, 2:487-489, 1940.
Johnson, Stephen L., THE HISTORY OF CARDIAC SURGERY, Johns Hopkins Press, 1970, pp 132.
Ibid.; pp 11-12.
- MacPherson, Maj. Gen. Sir W.G. et. al., HISTORY OF THE GREAT WAR -- MEDICAL SERVICES SURGERY OF THE WAR, VOL. 1, H.M.S.O., 1922, p431.
Co-author Dr. Alan Coulson (second from right)
performing heart surgery in 1996.
Dr. Alan S. Coulson is a Cardiovascular and Thoracic surgeon practicing in Stockton, California. His hobby is the study of the First World War, particularly the Somme and Ypres. He and his wife Jan joined the Great War Society's 1991 Western Front tour. This is Dr. Coulson's second article for RELEVANCE. Michael Hanlon is Research Editor and frequent contributor to RELEVANCE. He will be leading battlefield tours of the Western Front and Italy in 1997.