Far away, the minute hand of the ivory clock ticked and jumped ahead.
At the foot of the table, performing his role of observer, Dr. John Garrett exhaled tension through his mask and knew that the cardiac surgery, scheduled to last an hour and a half (after the long interlude of hooking the patient to the bypass machine), was at the midway mark. Soon, all too soon, Garrett would be able to return his attention to the taller, bulkier gowned figure of Dr. Carlo Farelli beside him.
Earlier, in Öhman’s office, in the dawn indistinguishable from the night, he and Farelli had met face to face without the exchange of a single cordial word. Öhman, sensitive to their animosity, had deftly come between them to seek their advice in charting the difficult cardiac transplantation. Except for two interruptions-one by a colleague on the telephone to discuss some youngster’s congenital heart defect (cor triloculare bi-atriatum), and the other by another colleague, who had poked his head in, fretting, to report on the impending miscarriage, this morning, of the wife of a mutual friend-the team of three had worked steadily. Garrett had soon become absorbed in the preparations that had taken place, especially in the record of Anti-reactive Substance S administered.
They had debated all of the problems, so familar and elementary to them, of the new surgical technique for removal and replacement of the heart, putting special emphasis on preventing clotting within the blood circuits, and on fastening of artificial materials to the blood vessels, so that there would be leakproof connections that would also discourage clotting. Garrett had brought up the possible discrepancy in the blood vessel sizes-those of the calf’s heart might be smaller than the ones to which they must be attached-but Öhman had anticipated this and described his nonreactive adaptors. Farelli had brought up the advisability of a heterotopic transplant, but both Garrett and Öhman had supported locating the new heart in the normal anatomical position. Three mammalian hearts, only hours old, had been stored, and Öhman, Farelli, and Garrett had unanimously agreed upon the one to be grafted.
At last they had been summoned to surgery, and Count Ramstedt had been wheeled in. Everything had been efficiently readied. The patient had already been anesthætized, chest shaved and prepped, and merthiolate applied. The patient had received mild hypothermy to cool his system to 30° C. and he had received heparin intravenously to prevent clotting. The huge heart-lung machine stood ready, and the 4,000 c.c. of whole blood, cross-matched, awaited use in the event of emergency.
In his concern for the patient, Garrett had forgotten the presence of Farelli. At first, what was so well known to him-materials, procedure-seemed strange and otherworldly because of the quick singsong of the Swedish words that went from Öhman to his nurses and aides-läkaren and hud and bröstkorg and blod and ådra and skoterska and bedöva-and once, pulsen är mycket oregelbunden, which Garrett understood to mean that the pulse was irregular-and constantly, over and over, hjärta, hjärta, hjärta, which Garrett came to realize was heart, heart, heart.
But then, as Öhman flexed his fingers in the rubber gloves, and took the slap of the scalpel, complaining that there was a troublesome halation on the instrument and having one light adjusted, and then, as he performed the median sternotomy-the incision from the neck base down the middle of the sternum to the bottom of the breastbone-there was nothing any longer strange or otherworldly to Garrett.
As he observed what followed, Garrett’s pride swelled. This was his discovery, his immortality. Critically, yet with continuing inflated ego, Garrett watched a son of Hippocrates attempt to raise a Lazarus from the dead. Garrett watched, his head involuntarily nodding its approval… the rubber-shod clamps… the open chest wall… the anticoagulant… the endless connecting of the plastic heart-lung apparatus to provide oxygenation of the blood and to remove carbon dioxide… the withdrawal of all blood from the major venous return before it reached the ailing heart, bypassing heart and lungs, diverting the blood through the pump and then returning it to the arterial circulation system… the crucial minutes of surgery with the delicate excavation of the old heart, transecting the pulmonary artery and the aorta beyond their valves and cutting across the region of the atria at the back portion…
It was 10.52 in the morning.
The strain began to leave Garrett as his protégé inserted the cooled fresh calf’s heart-two young mammalian auricles and two ventricles-and then sutured the walls of the atria together, avoiding separate anastomoses of the veins leading to the heart. Now, for the final suture by the Russian vessel instrument, woven dacron to hook up the aorta, the pulmonary artery, the four pulmonary veins, the superior vena cava, the inferior vena cava.
Garrett and Farelli looked on tightly, as Öhman completed the transplantation. With the new heart freed of air to avoid air embolism, Öhman released the aorta to permit fresh oxygenated blood from the great plastic outer machine to pass into the coronary vessels. The new mammalian heart warmed and was filled with fresh oxygenated blood. Gradually, gradually, the new heart began to contract, to take over circulation on its own, receiving and pumping plasma. The patient breathed on. Lazarus alive.
Garrett’s gaze narrowed. Rhythm excellent. No electrical defibrillation necessary. He was about to speak up-there was another thing-he must remind Öhman to administer Polybrene to neutralize the heparin and to allow the resumption of normal blood clotting, but then he knew it was too soon and Öhman would not forget, anyway.
The lanky anæsthetist spoke. ‘Oxygenation satisfactory. He is also maintaining satisfactory blood pressure.’
Seventy beats a minute, thought Garrett, and 5,600 c.c. of blood pumping a minute-with a transplanted heart! His own private heart swelled once more.
‘Go off bypass,’ said Öhman.
The glass cardiopulmonary heart-lung machine was disconnected. The new heart was on its own.
Only three times, in English made awkward by emergency, had Öhman consulted with Garrett and Farelli in the hour gone by, and three times they had confirmed what he had planned, once both supplementing his ideas with ideas of their own, and now, at last, the transplantation had been successfully accomplished. All that remained was the routine removal of clamps and catheters, the closing of the chest cavity, the addition of Polybrene, the injection of growth-inhibiting hormones to contain the calf’s heart, and finally, the observation of life renewed and extended.
Öhman turned to the Nobel winners, and Garrett thought that he might be smiling wearily beneath the mask. ‘His Majesty will be relieved,’ said Öhman in an undertone. ‘It is done.’
‘Benissimo,’ said Farelli. ‘Felicitazioni!’
‘Congratulations, Dr. Öhman,’ said Garrett.
‘No-no-it is I who congratulate both of you for this,’ said Öhman. ‘I can handle the rest myself. Why do you not wash up and wait in the office? Nurse Nilsson will show you the way. I shall join you very soon.’
He had already returned to the patient, and the tiniest of the three nurses came towards Farelli, and Garrett followed them out of surgery into the antiseptic, tiled washroom of the Caroline Hospital. The nurse hung back as Garrett and Farelli worked free their rubber gloves and removed their surgical masks, and then, still unspeaking, bent over separate basins to scrub the starch from their hands with nylon brushes. Drying his hands, while Farelli still washed, Garrett was relieved by the presence of the nurse.