Dr. Dwight Harken

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WGR (W. Gerald Rainer):  This is #2 in a series of historic interviews with pioneers in cardiac surgery.  Tonight we are in Boston at the home of Dr. Dwight Emary Harken who is one of the foremost pioneers of our time.  I think it is important at this point to describe the setting.  We are in the study of Dr. Harken's home which is replete with numerous bound volumes of all sorts, but more significantly, all of the mementoes of his accomplishments and triumphs over the years in his experience in cardiac surgery.  Dr. Harken has been kind enough to share with us tonight some of his experiences in the early days in the development of surgery of the heart, in which there were no ground rules, in which he along with others helped to develop some of the techniques that are so commonplace today that we take them for granted.  Dr. Harken will start with a preliminary introduction to how he came into cardiac surgery and take it from there, hoping to preserve for posterity the important events in his life.  Dr. Harken.

DH (Dwight Harken):  Jerry, that is so nice of you to introduce me as a pioneer and I would first like to say very quickly how it happened I thought we should operate on the heart.  Because before World War II, I had the great opportunity provided by the New York Academy of Medicine to go any place I wanted to go and work with anyone with whom I wanted to work on any specialty that might be elected.   And I was excited about this new and promising field called thoracic surgery.  And Dr. Edward Delos Churchill, my old mentor at Harvard Medical School, told me that the best place to go would be the Brompton Hospital in London and work under that brilliant technician, Tudor-Edwards. 

So I went to work with Tudor, and Tudor was an extremely exciting man and forever an inspiration, but the thing that interested me most was that he was always taking out cancers by surgical resection and always carefully avoiding the heart.  Now, it seemed like a strange thing to me to try to control the physiologic and biologic phenomenon of cancer growth with a knife when there next to where he was working was a pump that obviously should be attacked surgically.  If physicians are mechanics, it is up to them to attack mechanical things by whatever means at their disposal, including physiological means but, for Heaven's sake, take advantage of the fact that here is a mechanical structure that ought to respond to mechanical means.  So, when war interrupted my work with Tudor-Edwards, I came back to the Boston City Hospital Surgical Research Laboratories, where they let me work with surgery or experiment with surgery on the inside of the heart. 

Now, what does one have to have to have a license to do something that has never been done before?  Well, you have to have some diagnosis that is absolute, a condition that is incurable and, then, if you have any rational concept of how you might attack it, you have right to try.  Such a condition was bacterial endocarditis. The diagnosis was absolute.  In those days the mortality was 100% and, as I looked over the specimens in the Mallory Institute, it was very interesting that about 20% of these people had a vegetation on the flow side of the mitral valve.  There might be other valves involved in many other patients, but at least in 20% there was only that one vegetation. I had to presume that if they were autopsied at the Mallory Institute, that it was a very advanced stage of the disease.  Therefore, if I could develop an instrument, something like the cystoscopes that our G-U people were using and could look into the heart and see a vegetation and resect it, I might well cure an otherwise incurable disease. 

Well, how to do this?   Presumably this is a very advanced stage of the disease and, if I could take off the vegetation at an earlier phase, namely while the patient was living, we might cure the patient.  But I had to produce the disease first.  That wasn't very difficult.  I worked out a mechanism of getting into the heart and hooking up a safety pin on the mitral valve and then when thrombus formed on that safety pin, I would try to resect it.  Because the thrombus was always infected, the dogs always had bacterial endocarditis.  Just about the time I thought we were going to be able to look at vegetations, resect vegetations, and have a chance at operating on the inside of the heart, the war, that had taken me away from England and interrupted our work there, brought me back with the military forces of the United States and stopped the research work.  But, as serendipity would have it, by a series of mechanisms that may or may not be well known to you, I became the consultant in the European theater and saw young men with foreign bodies in their hearts.  And it seemed to me that this was not unlike the foreign body that I had planted in these young mens' hearts and I thought that they might develop bacterial endocarditis, they might develop effusions, they might embolize themselves, or they might produce emboli through associated thrombus.  And I consulted many of the senior mentors around London and I asked them what they thought of the logic of my reasons for resecting them. 

Indeed, I consulted Gray Turner, who was then the President of the Royal College of Surgeons, and he said, "Yes, young man, everything you said is logical. There are all of those reasons for trying to take shell fragments out of the heart. But you have left out an important reason.  The last and final reason is the full knowledge of that young man that he harbors an unwelcome visitor in one of the citadels of his well being."  So, with that support, that of Tudor-Edwards, that of General Hawley, and Elliott Cutler, we did remove shell fragments and there were 19 shell fragments in the chambers of the heart and they were all removed.  There were 134 shell fragments in or in relation to the great vessels of the heart;,they were all removed.  And because we had the greatest surgical risks in the world, namely rugged young soldiers, and reasonable anesthesia and reasonable surgical technique and a mechanism of transfusion, all of the patients lived. 

So, the first consistently select successful elective intracardiac surgery was on its way.  It might be of some interest to you to have you know that on occasion, one of those shell fragment operations and removal, a young surgeon by the name of Russell Brock was in the audience and at the end of the operation he said, "Dwight, what useful purpose can this be turned to?  After all, there are no shell fragments presumably going to appear in peoples' hearts in a peacetime situation"; And I said, "But your late departed Larry O'Shaughnessy showed us pictures of congenital pulmonic stenosis and we could certainly get at that the same way you saw me get at that shell fragment today.  And I have seen examples of mitral stenosis that Dr. Cutler tried to get with a valvotome and I suspect that I could get at that stenosis exactly like I got at that shell fragment today.  So, I might try to do that."  My original intent had been to resect subacute bacterial endocarditis, always fatal, generally absolutely diagnosable, but, it had become curable by the release of Penicillin and while it, my original reason for doing heart surgery, became obsolete a new method appeared on the horizon by sheer serendipity.

WGR:  Dwight, that is magnificent.  Now, I'm sure at this point when you came back from the wars, you must have been just on edge to apply these newly developed techniques into other areas.  Could you take us on an evolutionary tour of what happened from then on when you came back to civilian practice? 

DH:  Well, obviously as I have mentioned, there were no shell fragments in the heart and I had hoped to open pulmonic stenosis and mitral stenosis.  It seemed logical to create selective insufficiency that didn't bother the patient or to make the best possible valve out of a stenotic valve, called "valvuloplasty" (and we did create that word) and, therefore, in June of 1948, we did perform our first successful valvuloplasty.  We were quite pleased with the survival of this patient and quite surprised and, with mixed emotions, had to admit to that.  Charles Bailey had carried out his so-called "commissurotomy" just five days before. Now, whether one gives priority to the first operation or the first publication is a matter of personal opinion. 

It just happened that I knew Joe Garland, the editor of the New England Journal of Medicine, pretty well so I published that year and Charles didn't publish until the next year; but he really beat me to the punch.  However, it was not all "beer and skittles".  It was pretty grim.  Actually, of the first patients I operated on, six died.  These were desperately ill patients- we all call the "Group IV patients" now.  And with the sixth death, I was so depressed that I came home in the middle of the morning (the patient had died on the table) and went up to my room and went to bed.  My esteemed colleague with whom I've been happily associated for many years, Lawrence Brewster Ellis, the cardiologist, came by late in the afternoon  and spoke to Ann Harken and said, "Ann, is he feeling pretty badly?" and she said, "Yes, he certainly is.  He says he's got other ways of living and supporting his family.  He's going to have nothing more to do with heart surgery".  Larry asked if he should come up to my room and see me then, and she said, "No, it would be better to wait until the next day".  The next day I did feel a little better and Larry came up and said, "I understand you say you are not going to do any more heart surgery" and I said, "That's right.  No responsible man would continue with the devastation that I have wrought with these people and no responsible physician would send me a patient". 

Larry said, "I think that's a terribly selfish attitude you have to waste these peoples' lives" and I said, "What do you mean, waste these peoples' lives?  I am trying to save the next patients' lives from surgery".  And he said, "No, you must have learned something from losing those six people.  Don't you think you should put whatever you've learned to good purpose?" and I said, "Well, I do not think any respectable physician would send me a patient".  And he said, "Well, I am generally considered respectable. I am the President of the New England Cardiac Society; I would certainly send you another patient.  I have never sent you a patient who wasn't dying and, if you would be willing to try again, I would be willing to send you patients"  And, we did start again and only two of the next fifteen patients died.  The others did remarkably well and closed mitral valvuloplasty was on its way. 

WGR:  Dwight, that's great.  That's absolutely great.  I think it is so infrequent nowadays that we can even sense the feeling and the emotions, you know, that went through those of you during those years and even those of us who came along a few years later.  But these were the days that set the pattern for what has established our current-day accepted practice.  And our current day accepted practice has become so accepted that we lose sight of the emotions that went into the early days which, in retrospect, weren't so many years ago.  Now, if we could, we would like to hear how you went from the closed approach to the mitral valve to the next step in your evolution of the application and the furthered application of cardiac surgery.

DH:  Well, the next step was really a grand step sideways or a short step backwards.  Because the wonderful, late, great C. Sidney Burwell had become well aware of the fact that patients who had a systolic murmur at their base radiating into the neck often had calcific aortic stenosis and when they had syncope, angina or left ventricular failure or combinations thereof, their life span was limited.  So he asked me if I could get into the heart and fix aortic stenosis the same way I fixed mitral stenosis.  I didn't have any concept of what devastating and astronomical pressures were being generated back of those aortic dams in aortic stenosis.  There was, after all, no left heart catheterization and we didn't know that pressures of 300 mm of Hg might be generated back of aortic stenosis.  So, not knowing any better, I went, as I had always done, back to the autopsy room and measured a number of hearts and found that, indeed, my finger could reach from a zone under the left main coronary artery, just between the circumflex and left anterior descending, and I could, for the most part, reach the aortic valve through a transventricular approach. 

So I told him that I had been able to fracture and dilate a few of those stenotic aortic valves and he said, "I have a nice lady from the North Shore who is having frequent syncope and progressive shortness of breath who I am sure is going to die very soon.  Would you be willing to try that operation on her?"  And I told the good lady exactly the situation and how I had never performed this operation, but Dr. Burwell knew what was going to happen to her if she didn't have something done, and I asked her if she would like a chance at this operation, and she said, "Yes".  So, with that information, Bill Derrick and his wonderful colleague, Sue Williams (his assistant anesthesiologist), gave the anesthetic and I exposed the heart; and I put a purse string around the upper portion of the left ventricle; and I made a little stab wound first with a bistoury and then a Kelly clamp and then insinuated my finger into the ventricle only to discover pressures previously unheard of in hemodynamic circles.  After all, if you measure the column of 300 mm of Hg, that's a column something like well above the operating light level, and such a hemorrhage did occur.  And, of course, I tried to stem this hemorrhage by pulling up on the tourniquet around my finger and it only tore and so I put in two fingers and then three fingers and then more bleeding and four fingers and then, after all, massive hemorrhage of that quantity is self-limiting.  And the dear lady succumbed. 

Again, with the emotion of the damned, I returned home and went to bed and, later that afternoon that wonderful Sue Williams appeared at our door with a note that she had promised the lady (the patient) she would deliver in the event of her death.  I did come downstairs in my bathrobe or dressing gown, did open the note, and it said, "Dear Dr. Harken:  Thanks for the chance.  A small portion of my estate has been left to see that this doesn't happen again" and signed by the dear lady, herself.  And that was the money with which the first instruments were purchased that we used to sew tunnels on the base of the aorta and made a closed approach through the base of the aorta and, actually, did do some patients some good, thanks to that devastating mistake when I operated on the wrong side of the dynamics of the tunnel. 

WGR:  Dr. Harken, so far I think we've captured the mood of the moment of the early days.  I sense that much of the time was spent in serious problems, serious problems in meditation, thereafter wondering and worrying sometimes to the point of almost morbid depression.  What about- did you ever have any lighter moments that might have boosted your spirit?  Made you more exhilarated?  Because, after all, these are the times that sort of keep us going, to continue.

DH:  "Of course, there are better times and there are better things".  I only meant to stress to you, Jerry, and the thing that we all ought to remember, that the pain of the pioneer is something different than the pain of losing one's patient under standard circumstances.  And I shan't belabor this point, but if you devise a valve or devise an operation and you have the confidence of your patient and you let the patient know what you propose for him that might help him; and that creation of yours for him leads to his death, that’s a unique kind of pain.  Of course, we are all disappointed when we resect an esophagus and the patient succumbs.  Or when we resect a lung and the patient develops a bronchopleural fistula.  But if we know we have done just as well as it could be done, then somehow we blame fate, the Creator, or the disease with that failure.  But when we've created the vehicle of death, the bridge to destruction, for our patient, that's another kind of pain - the pain of the pioneer.  But pains are not always that.  The pains are not always the thing we think about. 

Let me tell you what people with mitral stenosis are like and why they're special people to help.  Every surgeon worth his salt thinks his patients are the best patients, that they are the most important patients, that they are the ones worth salvaging, but I will give you a little index that will convince you, too, that patients with mitral stenosis are different and when rehabilitated they are better than ordinary people.  Let's look at the facts:  3 to 1 they are women and women in the best years of their life (20-50).  They've suffered a long time because mitral stenosis slowly, progressively limits them.  They can't take of their house; they can't have sex activities; they gradually become more and more limited:  they suffer a long, long time and people who suffer a long, long time become long-suffering.  Long-suffering means to be tolerant. 

So, now we have the first phase of our kind of person - a woman in her best years, long-suffering, and patient and tolerant.  Next, her life has gradually closed in on her to the point where she can get around less and less well.  So she has to become maximally efficient.  Mitral stenosis knows no limitations in IQ's, so we have the spectrum of people that are very stupid to very bright.  But within that unit- that voltage of IQ- they've learned to be as efficient as possible.  They make as few steps as possible to get their housework done.  When they go upstairs to the bathroom, they make a bed and pick up the kids' clothes.  When they go to the supermarket, they buy everything in one trip.  When they get confined to their house, they measure their steps like gold pieces.  Eventually, they become so limited that they only walk from their knees down. They don't swing their arms and swagger around.  They spend their steps like gold pieces.  So now you have a patient, long-suffering person who is maximally efficient to her IQ.  Next, they see their lives closing in on them.   They think it leads only to death.  And people who contemplate death revert to the family religion.  It matters not be they Muslim, Jew, Christian, or what have you.  Most of the standard religions of history are good philosophies that have stood the test of time and when that woman reverts to her family religion, she reverts to a good philosophy. 

So now you have a good woman;  you have a long-suffering, patient, efficient, good person;  and the next and final step, you have a key that, when turned, can emancipate this person when her mitral stenosis is corrected if they have the courage to face up to something that scares them to death - namely, a heart operation.  So now you have a long-suffering, efficient, good person with courage that you've now returned to society and, I submit,that's a better than ordinary person.  That is what makes rehabilitation among these people worthwhile.

WGR:  Dwight, that's superb.  Now, up to the present point, I think we have sensed the feeling of the moment in the developmental stages.  I would appreciate it if you, in the final closing moments of this particular tape, would give us your ideas of
1. Why you went into thoracic and cardiovascular surgery to begin with?
2. Did it develop as you would at one time have predicted?
3. What do you foresee for the future?
In short, I’d like you for you to have license to wrap this up as you see fit.

DH:  It was nice of you to give me a full minute and one-half to wrap up a lifetime and predict for eternity. So I can only say that it is quite simply why I went into thoracic surgery.  I admired, immensely, Allen Whipple, Edward Delos Churchill, Elliott Carr Cutler, Irving Walker, but could see no possible way that I could catch up with these great men in my lifetime.  They were doing superb surgery.  They were making progress within their own rather stereotyped channels, so, that if we were to try to do as well as they, it would be obvious that I could not catch up with them until they retired which was at least 25 years off.  So what do you do when you can’t catch up?  You run another race.  What else was there to do?  It looked to me like we should attack the organ that hadn’t been attacked, the heart.  It looked to me like the chest, with its chronic infections, was an undesirable area shunted, spurned, by those who would elect cleaner, tidier, more elegant surgery.  

So, if I could try a field undesirable to others, and unapproachable to many, this innovative approach should provide me with an open field with no competition.  And if one wants to gain seniority immediately, he enters a field, develops the field, and he immediately has seniority.  I don’t mean to seem frivolous in answering your question, Jerry, but there is some substance in what I’ve just said and I suppose what I am really saying is, “he who would not learn from the past is condemned to relive it”. 

Thanks a lot, Jerry.