The Heart Healers (20 page)

In mid-1958, Portland Oregon radiologist Dr. Charles Dotter challenged this conventional wisdom. He devised a special catheter with a balloon near its tip. He positioned his catheter just above the aortic valve, then inflated the balloon for a few seconds to completely obstruct blood flow from the left ventricle into the aorta. At the same time he injected X-ray-opaque dye through the catheter. The only egress for his injected dye was into the two coronary arteries that originated in the small space between the inflated balloon and the aortic valve. He created spectacular images of the coronary arteries in dogs, and all his dogs survived. Dotter had shattered the myth that injection of X-ray dye into the coronary arteries would induce ventricular fibrillation, and had set the stage for one of cardiology’s greatest breakthroughs, coronary angiography.

Three months later, in his Cleveland Clinic basement catheterization laboratory, cardiologist Dr. Mason Sones prepared to perform a routine catheterization procedure called aortic angiography, in which X-ray dye is injected into the aorta. Since the dye disappears in a heartbeat or two, he placed the catheter tip just above the aortic valve, and injected a large volume of X-ray dye (20 to 40 cc) over a very short period of time (two seconds). This flow rate is vastly greater than is possible with a human hand, so Sones was using a specially manufactured mechanical “power injector.”

Staring intently at the image of West Virginian Abner Darby’s heart, Sones gave the command to his cardiology fellow Dr. Royston Lewis to inject. The sudden surge of the dye through the small diameter catheter whipped the catheter tip like a garden hose. No problem there, that was typical. But this time, Sones watched transfixed in horror as the thrashing tip flipped into Darby’s right coronary artery, and the power injector blasted away with its lethal load. In that two seconds Sones had the sudden agonizing realization that like the captain of a firing squad, he was watching a man killed at his command. For a doctor there is no more devastating experience than to be the sole, unequivocal mechanism responsible for a patient’s sudden death. Sometime in their career, this happens to every interventional cardiologist and every cardiac surgeon. Sones saw that his own moment of searing self-recrimination had come. In a few seconds, twenty-seven-year-old Abner Darby would be in ventricular fibrillation.

Abner Darby’s heart stopped beating. Sones shouted, “Cough, Goddammit,” and yelled for Lewis to yank back on the catheter. He grabbed a scalpel … the Claude Beck strategy of direct cardiac massage and direct defibrillation still held sway. Then as quickly as it began it was all over. Abner Darby’s heart … straightlined for a few agonizing seconds … and then slowly began beating again. It was so fast that the briefly terrorized Darby coughed and never lost consciousness. A decade later when I learned coronary angiography, we knew that Darby’s heart rate response is common following direct injection of contrast dye into a coronary artery. But this was the world’s first time. In a mini-tribute to Mason Sones’s theory that coughing somehow helped to clear the dye from the coronary vessels we still shouted “cough” when the heart paused. Although I have remained suspicious about the totally unproven effect of the lowly cough for dye-clearing and heart-starting, my Harvard mentor Dr. Richard Gorlin assured me the cough represents the art, not the science of medicine. My view is that the cough gives us something to do while Nature bails us out of trouble.

The door of serendipity opened just a crack to give Mason Sones a transient but perfect image of Darby’s right coronary artery. Rather than let it close, he tore that metaphorical door off the hinges. Within minutes of what he briefly imagined was a horrifying doctor-induced death, Sones stormed triumphantly back to his office to announce to all within earshot that “We just revolutionized cardiology!” Legend has it that his long-standing secretary, Elaine Clayton, dryly retorted, “Again?”

Mason Sones had discovered the way for us to see CAD. In science the difference between fame and failure, between preeminence and mediocrity, can be how one deals with a mistake. The discovery of the wonder drug penicillin came from a lab mistake. Now Mason Sones was poised to turn his mistake into a turning point in cardiology. That afternoon Mason Sones did not explain away his mistake, he embraced it. Just hours after his roller-coaster ride from precipitous descent into despair and ascent to exhilaration, he made a quick instinctive leap. He realized that he could insert a catheter directly into a coronary artery, and inject contrast material. He could provide an incandescent image of the disease that was now the nation’s number one killer.

Mason announced to his fellow cardiologists that he would begin scheduling patients for angiographic study of their coronary arteries. As his friend Dr. William Proudfit recalled, “He recognized right away that this would revolutionize medicine. I thought it was amazing that instead of just being thankful that the patient hadn’t died, he recognized immediately that this was a tremendous advance.”

Until a disease has a name, medicine stands idle. Once it has a name, we define its symptoms and its physiognomy at autopsy and under the microscope. This information helps to define its cause, and finally its treatment. For most of mankind’s history CAD did not even have a name, its symptoms only becoming clearly recognized in the 1700s. Even so, it took another hundred years for pathologists to clearly define its features. Then another century passed before we began to define CAD risk factors, like smoking, blood pressure, and cholesterol. World War II hero Dwight Eisenhower, who suffered a heart attack during his presidency, for instance, had been a four-pack-a-day smoker during the war, unaware of its risk. After the war, images of obstructions in coronary arteries linked symptoms and cause, and stimulated the first creative treatments. We could see the cause of CAD. Cause precedes cure. The coronary angiogram marks the beginning of the end for CAD.

Let’s pause to credit dumb luck—serendipity—in science. History credits serendipity for the Greek mathematician Archimedes’ discovery of buoyancy and the English physicist Isaac Newton’s discovery of gravity. Perhaps our serendipity champion is Christopher Columbus, who according to author Dr. Morton Meyers “did not know where he was going, where he was when he got there, or where he came from when he returned.” A visit to Barcelona convinced me. His statue points not across the Atlantic toward the New World, but across the Mediterranean toward Libya.

But serendipity still requires an innovator. Sones and his constant cath lab companion Dr. Earl Shirey became the Tweedledum and Tweedledee of coronary angiography, meshing like the perfect fit of a torn bill. Sones created a catheter with a tapered tip and multiple side holes like a garden sprinkler so that the catheter would neither recoil nor obstruct the vessel. Together they found the perfect concentration of X-ray dye for coronary arteries, developed ways to manipulate the catheter into the openings of the right and left coronary arteries, and figured out the best body positions for separating the images of the coronary arteries from ribs and vertebrae. Demand for Sones’s catheter created an entire new industry around Glens Falls, New York—nicknamed Catheter Valley—and in a few years the company that fabricated his catheter sold its millionth device. Like many physician-scientists in his time, Sones made millions in profits for corporations, but not a penny for himself.

In those years
Reader’s Digest
magazine had a monthly feature called “The Most Unforgettable Character I Ever Met.” Were I asked to contribute, Mason Sones would be my choice. As a child Mason had struggled as a short, tubby unathletic kid with glasses. He resorted to outrageous, often hilarious behavior, which carried into his adult life. My first encounter with Mason occurred when I was a visiting professor at the Cleveland Clinic. Mason was now a legend, the world’s most recognizable name in cardiology. Eight years after he described it, I had learned the “Sones technique” of coronary angiography at Peter Bent Brigham, where his name was held in reverence. As he approached to welcome me, everything about Mason said unpretentious. Round-faced with glasses perched far down his nose, Mason was a short, stout, shambling sartorial disaster in a tie-less shirt. The shirt appeared to bear splotches from his most recent cath procedure. A bespectacled Homer Simpson. He clutched his constant companion, a cigarette. Even before speaking, Mason Sones’s appearance had announced to his young starched white shirt visitor, “I am a maverick.”

But as we strolled the halls, Mason became a force of nature: constant energy, exuberant with patients, nurses, doctors, and—on this day—me. He was endlessly talkative, colorful in language, curmudgeonly, unpretentious, feisty, outrageous, daring you to argue, cursing like a sailor. He threw all aspects of his complex personality at you at once. Mason was determined that you see it all. With his abundant talent and self-evident flaws, Mason Sones was quintessentially human. His biographer David Monagan describes him as “storming through the hallowed Cleveland Clinic’s corridors in a sweat-stained white T-shirt that made him resemble the lowliest janitor. Ruddy-faced, he bellowed, cursed, and cajoled, and left trails of assistants and nurses recoiling and guffawing by turns. When desperate to dictate case reports, he was known to kick in the ladies’ room door and roar that it was time for some secretary to get off the pot. ‘Type, type, type!’ was his only half-self-mocking staff greeting in the morning.” Mason was legendary for his extraordinarily long workdays and his hard-drinking nights. Unpretentious Mason Sones was an unforgettable one-of-a-kind lovable misfit to everyone he encountered in life.

Possessed by a vision, Mason Sones was Steve Jobs in a lead apron, a man who took responsibility for developing every small detail of his discipline. He worked with engineers to create catheters, larger imaging devices, and wider movie film. And in the end, like Jobs, he transformed his world. Sones changed the unseen to the obvious, the unobservable to the observable. For the first time, we could actually see our enemy in every patient. The lurking atheroma, the cholesterol plaque in the blood vessel, the cause of angina, heart attack, and sudden death, had finally been exposed.

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AND THE REST
of the Story? Sones’s coronary angiography completely eclipsed radiologist Charlie Dotter’s idea of visualizing the coronaries by transiently obstructing the aorta with a balloon. But Charlie still had the last word. He sent his radiology trainee Melvin Judkins to Cleveland to learn Sones’s new technique. Judkins saw the one flaw that Sones overlooked. Manipulating a catheter into the tiny orifices of the two coronary arteries required consummate technical hand-eye coordination, precise knowledge of the anatomy of the aortic root, and the ability to translate a two-dimensional image into three-dimensional reality. In Boston, it took me a full year to learn the Sones technique. Judkins reasoned that since the coronary artery origin was always in the same anatomic location, he could develop a set of special J-shaped catheters for aortas of different diameters. With Judkins’s catheters, a virtual novice could now catheterize the coronary artery, with minimal catheter manipulation, and markedly reduced X-ray exposure time. The Judkins catheter replaced the Sones catheter in a matter of a few years. Melvin Judkins, like Sones, never patented his invention and never profited from it.

Late in his career, Sones was showered with awards. He loathed the pomp and pretension of black-tie banquets, especially those with honorees. His biographer David Monagan relates a quintessential Mason Sones moment, told to him by William Proudfit, which occurred in the early 1980s. Cleveland’s Stouffer Foundation had selected Mason as the honoree for their annual black-tie affair, which brought together the city’s most prominent citizens in a once-a-year spare-no-expense gala. The previous year, Spain’s Queen Isabella, the namesake of the Queen who launched Columbus’s exploration of America, had been the honoree. Mason being Mason sought refuge in the bar. After the speeches extolling Mason’s humanitarian virtues, scientific brilliance, and place in history, the Great Man was called to the stage. Mason wobbled to the podium, gripped the lectern, and paused. A hush filled the room as the crowd awaited the insights of their most accomplished citizen.

“You know, it’s the environment,” said Mason. A long pause.

The multitude sat baffled. What in the world could that mean?

“It’s the environment for sure. If anybody thinks you’re an asshole, they call you an asshole.” And with that, Mason Sones began his long staggering stroll back toward his seat. For a long moment, the audience looked at each other in stunned disbelief. Then someone stood to clap, and in a moment the whole room stood to applaud Mason Sones. The man is an eccentric genius, but he’s one of our own. And that is why his boss Dr. William Sheldon called him, “the stormy petrol of cardiology.”

It was not the first time Mason had appeared drunk in public. We in cardiology had seen him stagger across the stage at medical meetings. But when you looked at Mason Sones you had to see the whole man: brutally honest, self-critical, unpretentious, hilarious, generous, hardworking, innovative, bombastic, lovable, imperfect Mason.

Mason died as he had lived, with a cigarette in his hand, of lung cancer.

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WHEN I LEFT
the academic confines of my internship at the University Hospital to drive cross-country to Los Angeles in the mid-1960s I had not yet seen a coronary angiogram. In my three-year Los Angeles County Hospital internal medicine residency were profound lessons in both humanity and medicine. I had far fewer supervisors. In contrast to my university years, many of my patients had hit financial, medical, and psychological rock bottom in their struggle to survive. Responsible for these often-desperate souls, I became deeply immersed in every daily detail of their care. A segment of my fellow resident physicians looked down on these people, contemptuously calling them “gomers,” allegedly short for “go home.” I saw the opposite: when treated with respect for their inherent humanity instead of implied disgust with their failures, you discharged a deeply grateful patient. At the university I had been immersed in facts, in the country hospital I learned humanity. Near the end of my residency when I finally became aware of the potential power of coronary angiography, I knew what I had to do. Mason Sones had proven that coronary angiography was feasible. I wanted to be part of the new generation poised to attack CAD. I had to return to academia, to Harvard’s Peter Bent Brigham Hospital.