Document aG5nLrM2n9oQ2v690BG7zNJR

FILE NAME: Kent (KNT) DATE: 1956 Apr 7 DOC#: KNT127 DOCUMENT DESCRIPTION: Newspaper Article - Surgery for Damaged Hearts - The Saturday Evening Post The Saturday Evening Dr Uf t fni nlr April 7,1956 - lot RUSSIA'S UPPER-CLASS HIGH JINKS By CHARLES W. THAYER SURGERY FOR DAMAGED HEARTS By STEVEN M. SPENCER } i At Boston's Peter Bent Brigham Hospital, Dr. Dwight Harken slits open, the constricted mitral valve of a damaged h eart This patient's affliction-- i mitral stenosis, or narrowingof the valve opening--is the most common heart condition presently treated by surgery. i 'i !I Ir , R. J They Repair Damaged Hearts ; i Today there is almost no kind of heart defect which surgeons cannot mend with a special knife and sewing needle. By Steven M. Spencer Postoperative checkup: Dr. Charles Bailey, famous Philadelphia heart surgeon, finds Robert Ritter -.recovering successfully from an operation to correct a leaky mitral valve. Dolly Tondo before surgery and, with Dr. Hugh Wilson, several months afterward. Boston specialists saved Dolly's life by patching up a hole in her heart. A mitral-stenosis operation. After the first incisions are made, the heart is exposed by pushing aside the lung, slitting the pericardial sac and holding it open with several tie sutures. Then the surgeon widens the mitral valve with a knife attached to his finger. The mitral valve (here seen from above) controls the passage of blood from one chamber of the heart to another. When this valve is constricted (center) it hinders circulation and restricts a person's activities. Surgery permits blood to flow normally again. NORMAL MITRAL VALVE STENOTIC MITRAL VALVE AFTER VALVULOPLASTY Fo r c e n tu rie s doctors hesita ted to lay a finger, pioneer in h e a rt surgery, D r. D w ig h t E. m uch less a knife or needle, upon the h u H arken, of Boston, helped delay developm ents m an heart. T hey were afraid their slight on this frontier for nearly half a century. Not est to u c h w o u ld stop its life-sustaining b e a t. until the 1940's d id th e b a rrie r of skepticism Even such a bold and skillful operator as the and unreasonable fear begin to crum ble. Scores great T h e o d o r B illroth, of G erm any, w arned of soldiers w ith bullets and.shell fragm ents in in 1883 th a t " th e su rg eon w ho w ould a tte m p t th eir h earts forced th e su rg eo n 's h a n d . D o cto r to su ture a w ound of the h eart w ould lose the H arken, himself, as chief of the first T horacic respect of his colleagues." Surgical C enter in the E uropean T heater, lo A few m en did risk censure by sewing up an cated in E ngland, extracted such h ardw are occasional sta b w ou n d in the forbidden organ. from w ithin or aro u n d the hearts of 134 m en in Beyond th at, how ever, they d ared not go. A nd 1944 and 1945, w ithout a single fatality. in 1896 th e British physician, Stephen Paget, Encouraged by success in rem oving these concluded th a t h eart surgery, elem entary as it foreign bodies and in working on the large then w as, h a d " probabLy re a c h e d th e lim it set arteries an d veins n e a r th e h e a r t --as in th e by N atu re to all surgery: no new m ethod and patent ductus operation of D r. R obert Gross, no new discovery can overcom e the natu ral of Boston, and the " blue baby" operation of difficulties th a t a tten d a w ound of the h e a rt." D r. Alfred Blalock, of B altim ore--surgeons H appily, Paget proved to be a poor prophet. moved on to m ore com plicated rep air jobs. B u r his altitu d e was typical of the m ental " W e discovered th a t th e h e a rt w asn 't su ch a block w hich, in th e opinion of a present-day mysterious and untouchable thing, after all," D octor H arken rem arked, referring to his own and other operations, " and th a t we could enter it, do things to it and get o u t again, if we just followed the rules of the gam e. O n e rule, for exam ple, was to avoid tu rn in g or dislocating the heart from its norm al position, since such m anipulation could tw ist the. g re a t vessels, obstruct the outflow of blood and cause dis turbances in the h eartb eat." By following the rules as they learned them , and by com bining caution w ith a dash of bold ness, the h eart surgeons hav e w ritten one of the m ost exciting chapters in m odern m edical history. T o d ay th e re is alm o st no ca rd ia c de fect, congenital or acquired, w hich they have not corrected w ith their knife an d sewing needle. And thousands of m en, women and children, formerly doom ed to invalidism or early death, are now going m errily about their work and play, supported by expertly m ended hearts. (Continued on Page 91) " April 7, 1956 (Continuedfrom Page 89) Marxism which, I dare say, Marx would have found bewildering. B ut suppose you've already bought a car, given your wife a mink coat, built yourself a country villa and insured your accumulated wealth, and still you have money rolling in from royalties or com m issions? The Soviet Government launches each year a universal state 2 per cent loan, which will be deducted from your salary before you even see it. Your subscription to the loan is nonnegotiable and runs for twenty years, during which time it earns 2 per cent interest. In the past, you could subscribe as much of your salary as the party operatives could per suade you to give up. But the latter have now been forbidden to ask for more than two weeks of a comrade's salary. During my two m onths in Russia I found no one who had not "voluntarily" subscribed the full two weeks. In addition to the 2 per cent, there is a 3 p er cent loan which is known in local Soviet slang as the " gold loan." It has a lottery feature attached whereby you can win up to $25,000 in one of seven draw ings. The loan is negotiable and you can buy and sell it in unlimited amounts in any bank. I asked a bank clerk why any one in his right mind would invest in the 2 p er cent loan when he could buy the 3 per cent " You don't understand," she said. "They are two entirely different things. One you buy and the other you subscribe to." But, I objected, if lh a d 10,000 rubles to subscribe or use to buy, there was no question in my capitalistic mind which I'd do. "But we subscribe to the two per cent because we want to help our government finance our industrial program," she ex plained. I dropped the subject. There is one last way you can spend your extra income, as any parent in the world will tell you--on your children. The old communist tenet that the state would take over the bringing up of chil dren has long since been discarded and the role of the parent has been re-empha sized. You may find it difficult to buy a car for your son, though it is occasionally done. Y o u . can, however, give him a country villa where he can entertain his friends and spend his vacations. If he is backward, you can provide tutors to help him get into college--college is a must for the well-to-do. Finally you can give him an allowance. Pocket money up to $250 a m onth is n o t unusual for children of the well-to-do. B ut what can the children do with their allowances? There are movies and the aters. There is always the possibility of a little party at the country house, with plenty of liquor and girls. And then there are the bars of Moscow. If the dreary, humdrum life in Russia is so dull that it drives adults to drink, it often drives the young people to even stronger solutions. The Soviet press is constantly ranting about "the excesses of youth." One newspaper even printed a gruesome tale of a band of six young men in search of something more exciting than a Soviet movie who planned a bank rob bery. One of the boys threatened to snitch, and his body was found months later in a swamp outside Moscow. The plot was discovered and the boys sent to jail. Though the names of five were published in full, the name of the sixth was appar ently too prominent for publication and was not printed. In other respects immorality among the youth is causing headaches to parents and government alike. In 1936, during my first assignment to Russia, Stalin had pro hibited abortions and the sale of contra ceptives. But prohibition in this respect proved no more successful than pro hibition of liquor in America. Abortions continued to be performed by unlicensed practitioners, resultingin frequent deaths. On my current visit, contraceptives were being sold at all drugstores, including the kiosk at Moscow University. Last De cember the government announced that due to the injurious effects of illegal abortions, their performance would once more be legalized. One of the chief diversions of bored Soviet youth is to become a zoot-suiter, known in Soviet slang as "stifyag," or style-chaser. Their badge is long hair, narrow trousers, odd hats and brightcolored neckties. They can be seen any Saturday night walking up and down Gorki Street or in the Moskva Hotel Bar and nearby restaurants. The chic among them pretend to speak only Latin or Eng lish. They have rechristened the streets and sections of Moscow with such foreign names as "Broadway" (Gorki Street), " Piccadilly Circus" (Theater Square) and "Brooklyn" (the area across the Moskva River from the Kremlin). The gilded youth of the well-to-do are by no means the pinnacle of the Soviet so cial structure. F ar above them gyrates another galaxy known as the "Jet Set." These are the children of the very top communist leaders, marshals, composers and writers. Whereas the gilded youth number in the millions, the Jet Set is con fined to a few score stars. The well-to-do count their fortunes in the thousands of 91 rubles, but the Jet Set often has financial reserves into the millions. Some of them are orphans or widows of generals who lost their lives in World War II and have pensions amounting to as much as $1000 per family a month. But most of the money comes from royalties for musical and literary works or political tracts. When, for example, a leading communist makes a major speech, it is often dis tributed in millions of copies. From these he gets huge sums in royalties. Income taxes are seldom more than 11 per cent and inheritance taxes are a flat 10 per cent. It is therefore possible for chil dren of top leaders to inherit immense fortunes. This enables them to live in great luxury without lifting a finger. At least one such heir owns three country houses, keeps two apartments in Moscow and has fpur private cars. Asked how many millions he had, he replied, "Damned if I know." The Jet Set are a class to themselves. They regard the gilded youth of the wellto-do as new-rich and vulgar. N ot even all the offspring of the top leaders are ac cepted. For example, the Jet Set regards the children of Mikhail Pervukhin, mem ber of Russia's highest ruling body, as "lowbrow," like their father. The Jet Set marry almost exclusively within their own circle and'change marital partners with bewildering rapidity. As for the masses, they simply do not exist for "the cream of the cream." The Jet Set crowd has no contact whatever with those who stand in lines. Even at the super-strict Moscow Grand Opera House, where, after performances, foreign am bassadors wait patiently in long lines at the cloakrooms, the Jet Set sweeps ahead and gets its mink coats, and no one raises a murmur. The public of Moscow is too well trained to object to such antics. Money has no meaning for-these new aristocrats. They think nothing of stop ping at a flower shop on the way to a party and buying it out for their hostess. Their current craze is collecting old porcelain. Their greatest passion is for foreign thingsi--from cars to phonograph records. They would give their shirts for a trip abroad. In summer the fash ionable place for them to go is Carlsbad, in satellite Czechoslovakia. Foreigners who have seen Carlsbad since the com munists took over deplore its decay. But for the Soviet upper crust it's the ulti mate in spa luxury. Whereas foreign ambassadors in Mos cow sometimes have country villas to which they bring their servants when they come to stay, Jet Set members often have several villas, each permanently staffed with a full complement of servants. It is in these villas that much of their social life takes place, including, on occasion, some rather wild orgies. The legalization of abortions had no meaning for these spoiled sons o f the great--they always found a doctor ready to perform the illegal operation. Politically, the Jet Set is completely loyal to the Kremlin leadership. Oc casionally, they bemoan the lack of a "strongm an to make decisions," but they are well aware that they, too, have prof ited from Stalin's death, for that ruthless old m an might at any moment have wiped the whole lot from the face o f the earth with a single phone call. However, they take no part in active politics and regard themselves as superior to Communist Party activities. " Pravda is not for us," one of them said recently. "When it calls Tito a hero one day, a swine the next, and a great and good friend the third day-- that may be fo r the masses, but it's not for us." Indeed, their belief in communism is the purest lip service. Enthusiasm for its teachings does not exist, and when some one tries to preach to them, they simply ridicule him with epithets. A few of the males in the Jet Set are more serious and have studied for the diplomatic service o r engineering, but for the rest, like the gilded youth they despise, their lives are a monotonous round of parties and boredom. Sometimes they en joy doing bit pieces in the movies. This is considered quite the thing so long as it's not done for money. But the rest of their time they spend trying to wangle a trip abroad as the secretary of a delegation or a helper in some sports competition-- anything for a look at Paris! Why does the Kremlin put up with these new classes which threaten the very structure of communism? The answer, it seems to me, is that the Soviet system de pends for its very life on its engineers, sci entists and managers. To make sure of their loyalty, the Kremlin has bribed them with privileges which in turn are passed on to the children--the gilded youth and the Jet Set. The price the un thinking mass of Soviet workers are pay ing for their freedom from terror may well be high. But how high a price the communist rulers are paying in sacrificing some of their most basic principles is for the future alone to tell. Editors' N o le-- Is communism, with its dreams o f world conquest, h ere to slay? In his third ond concluding article of this series, in next w eek's Post, Mr. Thoyer hos an Informed Ond convinc ing answer to this question. T h e y R epair Damaged H earts (Continued from Page 33) Som e have had abnormal openings be tween the right and left sides of the heart--septal defects--stitched shut. Others have had tight valves loosened up or have been equipped with plastic or cartilage baffles to make leaky valves close more tightly. In a few patients a gaping valve has been snugged up by a drawstring made of nylon parachute cloth or an eighty-two-pound-test fishline. Several people are wearing in their aortas, at the exit of the heart, a plastic ball valve that ticks away like the alarm clock swallowed by Captain Hook's dreaded crocodile. The largest number of heart-surgery patientrtJvre their new hold on life to a much simpler, but still delicate procedure. This is the one-finger operation--with or without a knife--designed to widen a m itral valve scarred and constricted by rheumatic fever. The valve, so-named be cause Its two leaflets, when closed, re semble a bishop's hat, or miter, funnels the blood from the left auricle down into the left ventricle, whence it passes out to the aortic trunkline. Mitral stenosisnarrowing o f the valve opening--is the most common heart condition presently treated by surgery. And the operation for it, perfected within the past eight years, has been basic to the development of the whole field of intracardiac surgery. The procedure is now being carried out by excellent surgeons in many cities of the world, and important contribu tions to the technique have been made by a number of them. But credit for originating the operation and bringing it to its present high level of safety and usefulness belongs mainly to three men. One of them, D r. Horace G. Smithy, Jr., of the Medical College of South Carolina, died in November, 1948, nine months after his first successful operation upon a mitral valve. The cause of his death-- mitral stenosis. The two others are Dr. Charles P. Bailey, professor of thoracic surgery at Hahnemann Medical College, in Philadelphia, and Doctor Harken, surgeon at the Peter Bent Brigham Hos pital, Boston, and associate professor of clinical surgery at Harvard. As a boy of twelve, Doctor Bailey had seen his father die from the effects of mitral stenosis, and he determined early ifi his medical career to do something about the condition. Both he and Doctor Harken were bom in 1910 and were in their thirties when they began ipsearch on the problem, arriving at solutions al most simultaneously. Their first success ful mitral-stenosis operations were per formed ju st six days apart in June, 1948-- Doctor Bailey's on the tenth, at Hahne mann Hospital, and D octor Harken's on the sixteenth, at the Boston City Hos pital. Both o f the first patients are still living and well. Associated with Doctor Bailey at th is time were D r. Robert P. Glover and D r. Thomas J. E. O'Neill, who have also been responsible for many improvements in surgical methods. Doctor Bailey and his associates in serted the index finger and a slender knife into the heart as the operating instru ments, a modification of a technique de scribed by a London surgeon, H. S. Souttar, som e years before. Souttar had tried it in only one case, however. Doctor Bailey called bis operation, a commis surotomy. D o cto r Harken, in his first operations, which he called valvulo plasties, employed a punch-like instru ment similar to those used by his famous predecessor in this field, the late Dr. Elliott Cutler, although he later changed to a finger-and-knife method. 92 The early triumphs of these pioneers were m arred by frequent failures. A high proportion of the patients operated upon in 1948 and 1949 died during or soon after surgery. This period of dark dis couragement was recalled by Sir Russell C. Brock, o f London, in a speech last year before an international symposium on cardiovascular surgery at Henry Ford Hospital, .Detroit. He and his associates at Guy's Hospital, at one point in their own development of mitral-valve surgery, had four successive deaths among their women patients. "Despair stalked before us and every one's m orale was low," Sir Russell said. "I remember saying to my team that we could do only one o f two things--give up or go on--that it was impossible to give up, as we were certainly in the right. The only thing, therefore, that we should do was to go on. We did continue, and had thirty consecutive successful cases." While the courage of skillful surgeons was an im portant factor, the courage of desperately sick patients was no less es sential to the forward march of cardiac surgery. D octor Brock remarked a t the Detroit meeting that he felt that "the great pressure to aid the development of mitral-valve surgery came not from the doctors, but from the patients, who, in their frustrated desires to obtain help in their disability, brooked no interference." One who refused to wait for the slow uncoiling of medical conservatism and protocol, afraid her heart wouldn't last that long, is a-dark-skinned, delicate-fea tured West Indian beauty named Dolly Tondo. Her trouble was a septal defect, a hole between the right and left auricles, rather than m itral stenosis, but her story dramatically illustrates Doctor Brock's point. F o r years she had tried in her na tive city o f P o rt o f Spain, Trinidad, to get help for her failing heart. Several years ago she journeyed tp England, only to re turn disappointed. Then her local doctor got in touch with D octor Harken and ex changed letters about her case. But Mrs. Tondo became impatient with the pace of the mails. And one day last July she took the money she had earned from sewing lessons, left her seven-yearold son with her mother, and boarded a plane fo r the United States--without let ting either physician know she was on the way. She felt she was dying and that this was her only chance. She landed in Florida and took a bus for Boston. Three days and nights later she arrived a t the Park Square terminal in a state of col lapse, too ill to call the doctor or the hos pital. The bus driver made the calls, and a taxi rushed her to the Peter Bent Brig ham Hospital, where she was placed in an oxygen tent and treated for heart failure. T h e re . followed several weeks of study and tests and, early in August, Doctor Harken and his associates operated. They employed low-temperature anesthesia (hypothermia), chilling her body in an ice bath tt> reduce its metabolic need for blood. This permitted them to close off the vessels to the heart long enough to open the right auricle and stitch shut the hole in the heart's inner partition. She was then placed in a warming bath to bring her temperature back to normal. She made a good,albeit slowrecovery, and two months after the operation left the hospital for a convalescent home. She has gained thirtythree pounds since the operation. Surgery fo r mitral stenosis is consider ably Jess risky and demanding than op erations to correct septal defects like Dolly Tondo's. And as the surgeons learned more about the dynamics and pressure relationships of the heart and its valves their score with the scalpel im proved. Dr. Frank Glenn, professor of surgery at Cornell, told a recent American College of Surgeons meeting in Philadel phia that the over-all mortality, as esti mated from numerous 1955 reports, is now down to 5 per cent. "And the risk of operation is decreasing," he added. Doc tor Harken reports that the figure for all but the very poorest risks--who consti tute about a quarter of the entire group-- is less than 1 per cent, which is no higher than that in the average abdominal oper ation. Indeed, the heart may in many In stances be safer to operate upon than an inflamed or stone-filled gall bladder. Doctor Harken classifies his mitralstenosis patients into four groups, ranging from those without any significant symp toms (Group I)--for whom surgery is not usually recommended--to the cardiac in valids suffering chronic congestive failure (Group IV). The majority of patients ac cepted for surgery fall into a middle classification, Group III, described by Doctor Harken as having" progressive symptoms, "so handicapping that their activities are significantly and increas ingly limited." O f his first 500 mitralsurgery patients, 342 were in Group III. The surgical m ortality among them im proved steadily over the years from 14 per cent to less than 3 per cent. Since making this analysis of the first 500 Doctor Harken has operated upon several hun- million years from now, the world m ay be filled with creatures who will stoutly deny th a t they ev er descended from m an. AE MCGEE dred more, and among the last 400 Group III patients there were only two operative deaths, a rate of one half of 1 per cent. The figures on the poor-risk patients-- those in G roup IV--are less cheerful. Doctor Harken and Dr. Laurence B. Ellis, eminent Boston cardiologist who has supervised the follow-up analysis of these cases, point out in the journal, Cir culation, that here the operative death rate, which covers those who die on the table or fail to rally in the postoperative period, has continued to remain at about 25 per cent. "This emphasizes the desirability of operating upon mitral-disease patients before they reach this terminal stage," the Boston physicians state, although they believe people should not be operated upon " unless they are substantially dis abled by their disease, and unless, in spite o f medical treatment, they are going progressively downhill." Even though the very-poor-risk patient may have only three out of four chances of recovering from his operation, this can be regarded as a worth-while gamble. For, as Doctor Harken says, they are "terminal cases, cardiac invalids." He calls atten tion to nineteen such patients who were acceptedformitral-valve surgery, but who a t the last moment refused it. Seventeen of the nineteen were dead within one year. Careful follow-up studies of the thou sands who have survived the operation reveal that more than 70 per cent have shown striking Improvement. This in cludes all groups, poor risk and good risk, although the percentage of good results has naturally been higher in the latter category. The measure of improvement is some times dramatic, indeed. For Mrs. Doris McSweeney, a pretty, honey-haired young Boston housewife, it meant the final re alization of hopes many times cruelly de ferred. She had been one of thousands of women whose heart conditions were THE SATURDAY EVENING POST frustrating their efforts to have a baby. A heart hampered by a constricted mitral valve--and in some cases the opening is no larger than the head of a match--can not pump blood through the body fast enough to take care of the woman's own normal activities. When it is forced to as sume the additional burden of nourishing a developing infant in the womb, trouble frequently ensues. Four times the McSweeneys thought they were going to have a baby, and four times the young wife lost it before term. Their disappointment was bitter. WhenDorisbecamepregnantafifth time her doctor talked to her about the possibility of terminating the pregnancy early in its course, for the sake o f her own health. But the McSweeneys are Cath olics. Their priest advised them that such action would not have the sanction of the church. In the meantime Doctor Harken had examined Doris and indicated she could probably undergo a mitral-stenosis operation even though she was pregnant. "I wouldn't be able to live with my con science, much less my religion," she told the surgeon, "if I didn't make one more effort at having a baby. So, if you think this operation will help me, I'm anxious to go through with it." In the third month of her pregnancy, Doris McSweeney entered Mt. Auburn Hospital. There D octor Harken per formed the operation, widening the con stricted valve to provide a more generous flow of blood for herself and her growing infant Her physical condition began to improve almost at once. Last June, at the scheduled time, she entered the hospital again for the long-hoped-for event. And on the afternoon of June twenty-fifth D octor Harken picked up the phone in his office to hear a young woman's excited and jubilant voice. "Surprise! Surprise!" she shouted. "It's twins, doctor! Twins! I've really hit the jack pot!" Today, chubby, blue-eyed Maureen and Michael McSweeney are among Doc tor Harken's prize testimonials to the value of mitral-valve surgery. When their mother brings them to his office he picks one up in each arm and marches proudly around the place to show them off. They are not, however, the only babies whose advent into the world was made easier and more certain by an operation on their mother's heart. His list includes twenty other women operated upon while they were pregnant, with subsequent success ful deliveries. One of these had triplets six months after her operation. For some unknown reason, mitral stenosis affects more women than men, and its insidious course can lead to tragedies more serious than the inability to bear children. Although the condition is usually attributed to childhood attacks of rheumatic fever--often unrecognized at the time--it may not give its victim trouble until she is in her twenties or thirties. Then, as the obstructed valve in terferes with the heart's blood pumping, the woman finds herself getting weaker and weaker. She cannot walk upstairs without panting for breath. She is tired out before her day's housework is scarcely begun. Her ankles may swell. As the dis ease becomes worse the back pressure in the blood vessels leading from the lungs into the heart causes fluid o r whole blood to seep into the lung's air spaces. This is called pulmonary edema or congestion of the lungs. It often comes as an acute at tack of gasping, wheezing and coughing of blood. These terrifying episodes are frequently brought on by unusual physi cal or emotional strain. "The emotional ramifications of this condition," Doctor Harken commented, "often lead to the break-up of a marriage and a home. For sex relations may be hazardous if not impossible for the woman with severe mitral stenosis, and there are cases where the husband, failing to appreciate the seriousness of his wife's condition, has left her. If there are chil dren, she is faced with the problem of providing for them alone. Because of her physical disability she may eventually be forced to place them in foster homes. She now feels completely deserted, her life ruined." D o c to r Harken is confident that cardiac surgery can prevent many of these do mestic tragedies. And to his task of re pairing damaged hearts he brings not only a sound surgical preparation but an unquenchable enthusiasm and an affec tion for his patients which obviously help in their recovery. His sense of hum or is also on tap for those who ar tense and worried about the ordeal they face. It is related that one woman, having been treated by various physicians and brought finally to the pointof operation, looked at him anxiously and said, "Doctor, I'm now in your hands and God's hands." To which Doctor Harken replied with a smile, " Well, I hope God scrubs." Before he himself scrubs for the opera tion he orders the patient studied thor oughly to make sure her condition is one which he has a good chance of correcting. First come X rays and electrocardio grams. Then, in many cases, a fine plastic catheter is inserted into the heart cham bers, via blood vessels in the arm, or through a hollow needle in the back, to measure pressures on either side of the de fective vaive. The pressure readings give a fairly reliable estimate of the size o f the valve opening. At Peter Bent Brigham these studies are made by Dr. Lewis Dexter and his associates in the cardiac-research division. Once the patient is wheeled into the operating room she is in the hands not of one surgeon, but of four, plus two anesthesiologists and three nurses--a highly trained team of nine people. Doctor H arken starts by marking out the line of the incision, a wide arc extend ing from the front of the chest around under the left breast and left shoulder blade. Then, with quick, sure strokes he cuts through the skin, fat and muscle. His assistants meanwhile tie off or cauterize the bleeding points. The surgeons expose the heart by push ing aside the lung, slitting the pericardial sac and holding it open with several tie sutures. Now th e heart can be seen clearly, pink and glistening and pulsating. Gently, without moving it from its normal posi tion, Doctor H arken explores the organ and its attached great vessels. Folded back on the main body o f the heart is the earlike auricular appendage, the thin-wailed tip of the left auricle. This is the vestibule through which the surgeon will enter the heart with his index finger to explore and operate upon the valve. To prepare for the crucial entry, the ap pendage is pinched shut near its base, by means of tw o curved clamps. Then purse-string sutures are stitched in place and a finger-sized slit made in the top of the appendage. As D octor Harken slips his index finger into the slit, his as sistants draw the purse strings snugly around it, meanwhile slowly releasing the clamps. The drawstrings keep blood from leaking out around the finger and the sur geon proceeds t o probe the valve opening with his finger tip. "This young woman has been very sick," he rem arks. "She was terribly thin and pale and she couldn't go up three steps without becoming breathless. And no wonder. T he valve opening is quite small--less than seven tenths of a square centimeter. I'd say." He pauses to ask the anesthetist about the blood pressure. 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Pain* lea, safe. Buy QETS-IT today! THE SATURDAY EVENING POST (Continuedfrom Page 92) he adds, as it speeds up momentarily. "We'll go slowly." The surgeon is often asked, "Doesn't this motion of the heart bother you when you're operating?" " Yes, of course it does," he replies. "But I'd be more bothered if it stopped." On rare occasions a heart does stop during surgery, and then the doctor quickly grasps it in his hand and begins to squeeze it, as you'd squeeze a rubber ball, manually pumping the blood along, stroke after stroke. He may have to con tinue this for an hour or more before an invisible control center called the "pace maker" takes over again. An electrical pacemaker devised by Dr. Paul M. Zoll, of Boston, may be employed, although nothing is quite so effective in this par ticular situation as the human hand. In many instances the surgeon can widen the constricted valve with his finger alone--finger fracture, the technique is called. D octor Harken opens it part way with his finger in this case and then calls for his "bread-knife valvulotome" to complete the task. This is a thin, flexible blade, a quarter of an inch wide, with a wavy edge and a flat shaft. He slides the instrument down flat along the surface of his finger, without removing the finger from the heart, rotates the blade ninety degrees to bring the cutting edge into po sition, and then moves finger and knife as one unit to slit the comers of the valve. " I think I've given it about a four square-centimeter opening now," he says. "This should be a good resu lt.. . . How's her pressure?" "It dropped to eighty," the anesthetist replies. " But it's going up again. . . . Ninety now." " Fine. We'll come out. . . . Get ready with the clamps." He withdraws his finger enough for the assistants to clamp the lower part of the appendage shut, then pulls it out the rest of the way as they close up the slit with the purse-string sutures. The pouchlike appendage, now considered excess tissue, is snipped off just above the clamp and the opening at the base is sewed up permanently. Not all operations go off as smoothly as the one just described. In many in stances the edges of the valve leaflets are encrusted with calcium deposits. Extreme care must then be taken lest fragments become dislodged and sweep out of the heart into vessels leading to the brain. Here they could cause an embolism and temporary orpermanent paralysis. There fore, when the surgeon's finger warns him of calcifications he immediately orders an assistant to "hold the head vessels." Pinching these arteries shut for a few sec onds will usually deflect any fragments into less critical parts of the circulation. T, make sure no paralyzing embolism has occurred, the patient, as she comes out of the anesthesia, is asked to say something and to move each arm and leg. The depth of anesthesia, by the way, is so managed that the patient isjust rousing to consciousness as the surgeons finish with the sutures. At that strategic moment be tween sleeping and waking, Doctor Harken leans over the table and says, " You're doing fine. It's all over. Your heart's fixed. You're going to be all rig h t" She opens her eyes drowsily, smiles and drops back to sleep. The nurses, specially trained in the care of heart-surgery patients, keep up this re assurance. The patient is thus given a good start on the road to psychological as well as physical recovery. Reassurance, before and after surgery, is also supplied by members o f the Mended Hearts, Inc., organized at Peter Bent Brigham Hospital and now number ing more than 1000 recovered heart-sur gery patients scattered throughout the country. Wearing the club pin, a red heart with a neat seam stitched across the front, they call on patients only with the ap proval of the physician in charge, keep their visits short and cheerful, resisting the temptation to talk about their own operation in ether-drenched detail. Addressing a group o f fellow Mended Hearts recently on the fine art of hospital visiting, Mrs. M. Stanley Livingston, of Belmont, Massachusetts, said, "It is suf ficient to point out that you can now walk around the block without huffing and puffing, whereas, before, you had to stop twice en ropte." One Mended Heart went out and won a golf tournament after his operation. A New Hampshire housewife took a holiday trip to Pennsylvania with her husband-- on a motorcycle. To some of those who ask whether they can drive a car after the operation, Doctor Harken replies, " If you drove a car be fore, you can drive again. If you didn't, you'll have to take driving lessons." Walter Abernathy, of Lynn, Massa chusetts, a past president of Mended Hearts, Inc., was directing a traffic survey for the Massachusetts Department of Public Works the night we looked him up to ask about his operation. He had be come a candidate for surgery, he said, not because his mitral valve was too tight, but because it had developed a bad leak. This incomplete closing of the valve is termed mitral insufficiency. So much blood flows backward into the auricle with each heartbeat that the patient suffers from ex treme weakness, as well as lung symp toms. For nine months preceding the op eration Mr. Abernathy was a semi-invalid, unable to walk across the room without leaning on his wife's arm o r hold ing onto the walls and furniture. Doctor Harken repaired Mr. Aber nathy's leaky valve in December, 1952, by suspending horizontally across the open ing a plastic plug two inches long and shaped like a soft-drink bottle. This "bottle baffle," as it is called, gave the otherwise gaping lips of the valve some thing to close on and prevented the hazardous regurgitation of blood. A similar technique for plugging leaky valves was devised by Doctor Bailey in Philadelphia. Instead of using plastics, he carved the plug out of a piece of rib cartilage and covered it with a strip of pericardium. He applied this method not only to mitral valves but to the tricuspid-- the corresponding valve in the right side of the heart--and to the aortic valve. Neither Doctor Harken nor Doctor Bailey, however, has been satisfied with his score on these plugging maneuvers. They and other surgeons have been striv ing for more physiological approaches. Studying the anatomy of the valves, they found that a certain proportion of them fail to close properly because the fibrous ring or base of the valve, from which the flaplike leaflets grow out, has become stretched and dilated. In other words, the space is so large that the leaflets can't possibly meet at the middle to close it. Doctor Glover and Dr. Julio C. Davila, at the Presbyterian Hospital, Philadel phia, found they could reduce the size of the dilated mitral ring by encircling it with a heavy purse-string suture. The drawstring was then pulled together until the valve leaflets met properly. The newest method of diminishing the size of a mitral-valve ring is that devised by Dr. Henry. T. Nichols, an associate of D octor Bailey's at Hahnemann Hospital and Medical College. Rather than at tempting to encircle the entire ring, he pinches it together at two opposite points and holds these tucks with heavy eightytwo-pound-test fishline. The procedure is similar to reducing a worn and stretched buttonhole to normal size by taking stitches across either end. As we stated at the outset of this article, no cardiac defect is beyond the reach of the modern heart surgeon. Some give him more trouble than others, of course, and one of the toughest is the aortic valve. It is the exit gate through which the powerful left ventricle discharges its full load of blood to start the journey around the body. Blood flows here a t higher speed and pressure than anywhere else, and the surgeon cannot plunge his finger through a simple slit in the aorta without risk of uncontrollable and fatal bleeding. N or is there any convenient appendage here to serve as an operating vestibule. e surgeons are so sold on the "vesti bule" principle, however, that they fashion an artificial appendage or cuff and sew it onto the side of the aorta. This provides a safe entrance for a finger or in strument during the aortic-stenosis op eration. Some of the doctors get their wives to make the cuff out of a scrap of nylon or rayon slip. Doctor Bailey now prefers to use a piece of pericardium, ob tained at post mortem and kept in a re frigerator. It is a thin, rubbery tissue and sewing it to a slit in the aorta, while a fold of the latter is pinched off with a clamp, is a slow, painstaking bit of needlework. But if properly attached it holds firm, without leaking, while the surgeon manipulates an instrument to cut open the fused valve leaflets. The aortic valve that doesn't close properly is still a challenging problem. The plastic-ball valve developed by Dr. Charles A. Hufnagel, o f Washington, has been one solution. But there are certain objections to it, and other methods are being tried. Since this discussion has dealt only with surgery inside the heart we have said nothing about the various operations per formed on the outer surface of the organ, aimed at increasing the blood supply to cardiac muscle impoverished by coro nary-artery disease. A great many meth ods have been developed over the past twenty years, notably by Dr. Claude S. Beck, of Cleveland. Among them are the grafting of a chest muscle to the heart, the attachment of a chest artery to the coro nary system, an d the sprinkling of pow dered bone or asbestos inside the peri cardial sac to stimulate richly vascularized adhesions. The powdering procedure was suggested for President Eisenhower, but was voted down by his physicians, includ ing Dr. Paul White, on the ground that his heart muscle was not so blood starved as to justify such an operation. Advances are steadily being made in this field, however, and th e day may come when this commonest o f all forms of heart dis ease, coronary thrombosis, may be re lieved, in its m ore serious forms, by sur gery. The heart surgeons are also looking forward to the time when they will no longer have to d o so many o f their intra- cardiac operations by the sense of touch. "These are hidden-ball plays," one of them quipped, " and we would much rather see what we are doing." Help in this direction is coming fast from the de velopers of artificial heart-lung machines. According to a newly organized American Society for Artificial Internal Organs, four heart-lung machines were in use at the time of its first meeting last June. Others have com e into operation since then. With the patient's circulation by passed through an apparatus that will pump and oxygenate the blood, the sur geon can work in an open and dry heart for an hour or s o at a time. Given this advantage, the possibilities for recon structing damaged hearts are almost limitless. THE END