Take a good look
at this picture. It's one of the most remarkable photographs ever
taken. The tiny hand of a foetus reaches out from a mother's womb
to clasp a surgeon's healing finger. It is, by the way, 21 weeks
old, an age at which it could still be legally aborted. The tiny
hand in the picture above belongs to a baby which is due to be
born on December 28. It was taken during an operation in America
recently. Paul Harris reports on a medical development in the
control of the effects of spina bifida ... and on a picture which
will reverberate through the on-going abortion debate
here
Your first
instinct is to recoil in horror. It looks like a close-up of some
terrible accident. And then you notice, in the center of the
photograph, the tiny hand clutching a surgeon's
finger.
The baby is
literally hanging on for life. For this is one of the most
remarkable photographs taken in medicine and a record of one of
the world's most extraordinary
operations.
It shows a
21-week-old foetus in its mother's womb, about to undergo a spine
operation designed to save it from serious brain
damage.
The surgery was
carried out entirely through the tiny slit visible in the wall of
the womb and the `patient' is believed to be the youngest to
undergo it.
At that age the
mother could have chosen to have the foetus aborted. Her decision
not to, however, led to an astonishing test not just of medical
technology, but of faith.
Samuel Armas has
spina bifida, which left part of his spinal cord exposed after the
backbone failed to develop.
The operation
was designed to close the gap and protect the cord, the body's
motorway for nerve signals to the brain.
So, on an unborn
patient no bigger than a guinea pig, the operation was performed
without removing the foetus from the
womb.
The instruments
had to be specially designed to work in miniature. The sutures
used to close the incisions were less than the thickness of a
human hair.
An ER-style
crash cart team was on constant standby in an adjoining
room.
When it was
completed, however, Samuel's battle for survival was only just
beginning. Nor would the emotional battle his parents had already
endured finish quite yet.
Julie and Alex
Armas had been trying desperately for a baby. Julie, a 27-year-old
nurse, had suffered two miscarriages before she became pregnant
with the child they intended to call Samuel Alexander if it was a
boy.
Then, at 14
weeks, she started to suffer terrible cramp. An ultrasound scan
was carried out to show the shape of the developing foetus and its
position in the womb.
When the picture
emerged, it was the moment that every parent-to-be dreads. Their
unborn son's brain was mis-shapen and his spinal cord was sticking
out from a deformed backbone. He had spina bifida. They were
devastated and "Torn apart" said Alex, a 28-year-old jet aircraft
engineer.
At that stage,
and even weeks later, the couple could have decided to have the
pregnancy terminated. In their home town of Georgia in the US as
in Britain abortion is routinely offered. Although accurate
figures are not available, many parents accept. For Julie and
Alex, who are deeply religious, it was not an
option.
That didn't
mean, of course, that they were not racked by pain at the thought
that the child they had longed for was
imperfect.
It also riddled
them with guilt over whether they had effectively taken the
decision to inflict their son with years of handicap, pain and
suffering.
So, this being
the United States, they turned to the internet for
help.
Julie's mother
found a web site giving details of pioneering surgery being
carried out by a team at Vanderbilt University in Nashville,
Tennessee. Although the results have not yet been endorsed in
medical journals, they looked encouraging to Mr. And Mrs.
Armas.
Their doctor put
them in touch with Dr. Joseph Bruner (it is his finger in the
photograph). A race against time had
begun.
Because it
affects the spinal cord, spina bifida can lead to a condition that
causes brain damage. Mr. and Mrs. Armas were told that if they
were to avoid the condition, which was not then present in Samuel,
they had to act fast.
"I wasn't
concerned about a child who couldn't walk," said Julie, "but I
want a child who knows me."
The theory
behind the surgery is that attention to he spine disorder before
the baby is born prevents or limits brain damage, and gives a
better chance of healing. It does not cure spina bifida, but it is
said to provide a strong chance of limiting the damage through
early intervention.
The risks,
however, are enormous. Controversy surrounds the use of such
surgery because it goes against the general medical rule that the
risk should not outweigh the benefit.
Mr. and Mrs.
Armas were fully aware that if anything went wrong, no attempt
would be made to deliver Samuel by Caesarian
section.
Medical science
does not yet have the capability to keep a 21-week-old foetus
alive outside the womb. The crash cart was on standby for Julie,
not Samuel.
"If he dies,
that's horrible for me and for us," said Julie before she went
into theater. Wiping tears she added: "But not for him. The worst
thing might be if we don't do this, and this is standard treatment
when he's 21, and he says:" "Why didn't you know about that?" And
we say: "We did, but we didn't do it for
you."
The other major
dangers were turning him in the womb to get his back in line with
an inch long cut in the wall, through which Dr Bruner would
operate, and that the surgery might involve releasing the fluid
around Samuel.
The movement
posed the risk of sending Julie into labor contractions, which
would have been fatal for Samuel.
Thus, one
morning at the beginning of last month, Dr Bruner could be heard
urging his team to keep quiet. "Shh!" he said. "You'll wake
the baby!"
Robert Davis,
who reported on the operation for USA Today newspaper, said the
lesion that exposed Samuel's spine was found low on his backbone,
decreasing the chance of nerve damage.
Although Samuel
is believed to have been the youngest patient for such an
operation, it was apparently routine enough for Dr Bruner and
pediatric neurosurgeon Noel Tullpant to talk about the weather
during the operation.
An hour later,
the womb is gently eased back into place. "Beautiful," said one of
the technicians and relief swept the
room.
Julie was
allowed home with Alex within days. The baby is due on December
28.
He has not yet
felt the touch of his mother's skin against his own and he knows
nothing of life outside her womb. But perhaps Samuel Alexander
Armas will be able to shake Dr Bruner's hand
again.
