by Rob Dunn
Williams rushed to Cornish’s bedside. Cornish’s blood pressure had dropped dramatically, but Williams was not sure what was going on. With his recent success at his back, he decided to open Cornish up again and conduct the second heart surgery in the world. He made a new incision, undid the original stitches, drained the space between the pericardium and the heart muscle, sewed the pericardium shut again, and then stepped back. It was, he thought, almost easy to work on the heart. Cornish left the hospital on August 30, 1893, alive.8
Cornish went home to his family and lived a long and largely happy life (one exception to that general happiness being a return to Provident Hospital with a head wound from another bar fight). He died in 1931, thirty-eight years after being stabbed in the heart. But the broader consequences lasted far longer than Cornish. Williams broke the barrier to the heart, the myocardial ceiling. Once surgery had been done on the heart, others began to operate too, and it would be Williams’s model, as well as broader changes in medicine, that built the first step that led to modern cardiology. We think of the medicine of hearts as well established, but the truth is that every medical treatment of the heart, as well as most of what we know about the organ, has come since 1893. In that year, one heart was operated on, twice. In 2010, more than half a million hearts were operated on in the United States alone.
The character in this story who really started everything, that man who stabbed Cornish in the bar, is forgotten. He could not have anticipated the series of events that would transpire thanks to his knife. To paraphrase Dr. Harry M. Sherman, speaking at the annual meeting of the American Medical Association in 1902, the road to the heart is only two or three centimeters in a direct line, but it had taken surgery nearly ten thousand years and a bar fight to travel it. Meanwhile, time and perspective have modified our understanding of the events surrounding the surgery Williams performed. That such a major advance was made in a poor hospital by an African American doctor and African American nurses just thirty-one years after the Emancipation Proclamation is astonishing. We tend to regard technology as the source of many innovations, and yet Williams’s advance was something different, progress through some combination of hubris, intellect, and will. He and the doctors and nurses he gathered around him had the necessary mix of wherewithal and confidence to try, and the skills to carry through.
Time has also added more context to the question of whether Williams was really the very first to perform a heart surgery. He thought he was, but he had actually been preceded by two years. In Alabama in September of 1891, another doctor, Henry C. Dalton, had performed a remarkably similar surgery (again on the victim of a stabbing), though the news would not be published until two years after Williams operated on Cornish.9 Williams’s prominent surgery was the one that made doctors aware of what was possible with a knife, a sewing needle, and some catgut.
We might hope that what motivated surgeons such as Williams to do new procedures was their goodwill toward humanity. There was some of that, but there was also the same motivation that drew Mallory up Everest: Mallory climbed Everest “because it [was] there.” Like Everest, the heart was there. The next step up the mountain was to actually cut into the muscle of the heart.
On September 9, 1896, a gardener arrived in the Frankfurt am Main hospital with his clothes soaked in blood, but once cleaned up, he seemed to be stable—until suddenly he was not. With the patient’s health quickly worsening, the surgeon Ludwig Rehn was brought in. It seemed as though the gardener would die. There was nothing more to do, a situation that emboldened Rehn. Rehn decided to cut into the gardener. He opened the man’s ribs and saw the heart. It was beating beneath a sea of blood, pumping and spitting. Rehn pushed his finger into the heart and found a hole. The feeling was marvelous. The heart slipped beneath his finger as it beat. He was amazed to find that it was strong rather than weak, as he had assumed it would be. He held his finger in the hole as best he could and then, seizing the moment (and a needle and thread), began to sew, one stitch for each beat. Rehn, like Williams, was successful10 and hopeful. As he wrote of the day, “This proves the feasibility of cardiac suture repair without a doubt! I hope this will lead to more investigation regarding surgery of the heart. This may save many lives.”
It did. In 1907, Rehn reported that 120 surgeries on the heart had been performed around the world, about 40 percent of which had been successful. The results weren’t perfect—they still are not, even though current mortality from the same surgery is just 19 percent—but they sure beat the near certain death that had previously been the outcome of stab wounds to the heart.
Before 1893, the heart was simply not touched. Beginning in 1893, it was touched and, surgery by surgery, more effectively sewn back together when damaged. There was a sense of progress even when, in retrospect, progress seems to have been slow. In 1923, Dr. Walter Lilienthal of Cornell Medical School noted in Time magazine that there had been major successes in heart surgery, and he went on to list inventions that today seem modest—a phonograph to record the sounds coming from stethoscopes, a camera set up to take pictures of the moving heart, the realization that adrenaline could speed up the heart (it had recently been injected into the heart of a seemingly dead baby boy and had saved him).11 Yet at the time, this all seemed like immense advancement, advancement that would only accelerate. There are many stories to tell about the years that separate Williams and Rehn from modern medicine, stories of ambitious individuals who believed they could conquer our most tempestuous organ in new ways, and of patients, be they presidents or paupers, who lived or did not as a consequence. Technical progress was made, sometimes to the benefit of patients, sometimes at their expense. Hearts were stopped and started again. Hearts were even moved, beating, from one human to another until such surgeries were perfected and came to seem, if not quite ordinary, at least mechanical. But before we consider the story of the past hundred years, let us begin with the story of the prior thousand.
2
The Prince of the Heart
It was an unbelievable moment. As spectators looked on, a man gutted a Barbary macaque in the middle of a city plaza. There, before the crowd, he challenged everyone to put it back together. The moment was madness, but the man was not mad. He was, almost inarguably, the most important medical scientist in history. His name was Galen, and this moment before the crowd was his coming-out as a performer and a scientist.
Galen, or Galenus of Pergamum, was born in AD 129 in Pergamum, near the Aegean coast of what is now Turkey. He was, at least by his own reports, a kind son and a dutiful student. Upon finishing school, and at the suggestion of his father, he traveled to Alexandria, the great city of learning. Galen’s father had seen in a dream that his son would be a great doctor. Galen would later speak often of this dream,1 emboldened by his father’s premonition to strive even more eagerly. Following his training and his father’s death, Galen looked to establish himself. He needed a livelihood. After the sort of wayward traveling that even today makes parents nervous, at the age of twenty-eight, he decided that he would like to begin his career as a medic to gladiators, once again in his hometown of Pergamum. There was a problem, though. He needed to be chosen from among many candidates. This was too important an opportunity to leave to chance.
Galen, the father of modern medicine, whose influence has yet to fully wane. (Courtesy of the National Library of Medicine)
The potential gladiatorial doctors were asked to meet in a public area. Galen is said to have brought with him a very hairy and ill-fated ape (actually a Barbary macaque). While the other doctors looked on, Galen eviscerated the macaque. This was his moment. It was madness; it was horrible. But Galen had his reasons. Standing above the animal, he challenged the men around him to put it back together again. No one but Galen could. He got the job (or, in some tellings, at least secured the job that was already his). Galen might have been trying to say that in order to tend to gladiators, you needed to be able to put their guts back together. But the message the other doctor
s probably heard was something more like I’m so crazy, I’ll cut open a macaque; you don’t want to try to take this job from me. Either way, it worked. Galen had already acquired some of the brash skill that would bring him fame.
Galen took up his position with the gladiators. He traveled with them during the winter, spring, and fall training months; he worked alongside them. He was a fight doctor, and his was a world of sweat and blood and well-trained men, men whose bodies and, particularly, hearts worked slightly differently than the norm. We know now that in an endurance athlete, the heart’s left and right ventricles expand in order to pump larger volumes of blood to the body. The relaxation of the heart between beats also becomes more extreme. By contrast, in a strength athlete, such as a bodybuilder, the heart’s ventricles do not necessarily get bigger, but they get stronger, and the heart relaxes less, rather than more. In the movies, gladiators look like bodybuilders. In reality, they probably looked more like chubby, small-town strongmen. They ate a special vegetarian diet of barley and fava beans to become somewhat fat, the idea being that the fat might help protect them from wounds. Yet, despite the fat, gladiators did exercise, and it seems likely that their bodies were the result of a mix of strength and endurance. One expects that their hearts were a mix, too—strong and big and never terribly relaxed.
In the summer months, fights were staged, and Galen would wait for the injured. A coliseum rose above him, and in its stands Galen could hear twenty-five thousand fans cheering and booing. They loved the spectacle of the gladiators battling in the dry dirt. The fans felt as though they were fighting too. Galen heard them cursing. He heard them moving. He heard their bodies above him, around him, a great mass of hands and legs, flesh, and, buried in the bodies—hidden but so easily revealed—hearts, livers, kidneys, veins, and arteries, all of which he knew were there and yet could not explain. As he stood in the heat of a crowd, he dreamed of greatness, but not that of the gladiators. He dreamed of his own.
The gladiatorial battles alongside which Galen stood were the precursors of all sporting events that would follow—every one you have ever been to. It is not hard to see the fans of gladiator events in the faces and actions of soccer or football hooligans. And the gladiatorial arena would be the precursor to the stadium, but also to the surgical theater. To Galen, the gladiators were titillating as they ran at each other with their weapons raised. But more titillating was the subsequent struggle, his struggle, to save the men who had been wounded. Anyone could kill a man. Only Galen could so consistently bring a man fated for death back to life, at least according to him. He wanted and felt he deserved a crowd.
Galen’s predecessor had lost many gladiators to injury. The wounds were too deep, infection too overwhelming. Gladiators died one after the other. But not on Galen’s watch. In the entirety of his time tending to the gladiators, just five men died.2 Perhaps being able to stitch up a macaque actually was useful in stitching up gladiators, or perhaps Galen was ambitious enough to be both self-aggrandizing and great.
As Galen sewed the bodies of gladiators back together, he made scientific discoveries. The bodies of the gladiators were specimens in which the muscles, nerves, and veins were, if not exactly obvious, then at least more obvious than in the average man. The gladiators could be learned from. Seventeen hundred years before Leonardo da Vinci would carefully sketch out the body’s external details, Galen was gaining daily experience with its internal ones. The gladiators’ wounds were, as Galen would write, “windows into the body.” It was thrilling for him to look into wounds. Was it joy, a kind of love? Galen would later do experiments in which he would track the heartbeats of lovers when they were reunited (or pulled apart). Love made the heart pound, and Galen loved discovery; it made his own heart race beyond his control. Today we know that love, rage, and other strong emotions affect the amygdala, a group of neurons in the most ancient part of the brain. The amygdala triggers the release of hormones that affect many organs, including the heart; the hormones can cause the heart to speed up, which sends more oxygen to the brain. All Galen knew was that he could feel this effect. He could feel his heart running as he saw the living, working parts of bodies, parts very few other people had ever seen.
In Galen’s Roman Empire, most doctors would not have seen the heart even in a dead body. The Romans waffled on what was necessary in the afterlife and so prohibited all human dissections; better to be safe than sorry. The sliced-open bodies of the gladiators would have to suffice for Galen. Working on these bodies, Galen sometimes paused longer than he should have, to look. He may even have seen a beating heart. (He definitely saw one later in life, when asked to tend to a boy with a chest infection. Galen cut into the boy’s chest and saw his beating heart. He may even have cut into the boy’s pericardium, two thousand years before the next such cut, by Daniel Hale Williams in Chicago.) Certainly, Galen saw the roads of arteries and veins. He saw enough to begin to sketch, first in his mind, then on a papyrus, a semblance of the intimate geography inside all of us. He was the first real geographer of our untraveled reaches—Captain Cook of the high seas of blood—and though he would err in how some of the regions connected, mistake some peninsulas for islands and so forth, his would be the map that would allow all of those who followed to proceed, to hesitantly check the boundaries he had so carefully limned.
As Galen continued in his role with the gladiators, he learned and profited, but the former more than the latter. He wanted more—more money, fame, and understanding. Eventually, Galen retired from his gladiator job and began to work as a sort of traveling doctor and showman. Doctors already existed, but their treatments had very little to do with actual diagnoses; Galen was, arguably, the first doctor who aimed to understand what caused ailments and then to treat those causes based on the results of testing the treatments on multiple patients. He had learned about science from Alexandria. Now he was learning to treat illnesses (not just mending wounds, which was his focus with the gladiators) by empirical trial and error. His doctoring allowed him to see more kinds of afflictions. His performances, at which he would dissect an animal, treat a patient in public, or otherwise make a spectacle, allowed him to both garner support and, however informally, teach. His research, which often occurred during public dissections and displays of doctoring ability, allowed him, each time he looked, to understand more. It was the performance and the research that motivated him; he wanted to understand and then be able to display that understanding to the masses.
During these years (and, for that matter, in the fourteen hundred years to follow), Galen had no rivals. Across the entirety of the Roman Empire, stretching from modern Scotland to Egypt, Galen’s accomplishments were lauded. He became a legend in his own life, so much so that at the margins of the empire, the story of his life became exaggerated, imbuing him with the status of a sort of half-god. His reputation traveled by word of mouth—in response to his performances, for example—but also via his writings. Galen wrote volume after volume about both what he had discovered himself and what was already known but not well consolidated. These volumes were greedily consumed throughout the Roman Empire and beyond. Thanks to this fame and success, Galen eventually became the physician to the emperors. He tended to their royal bodies with tender effectiveness, just as he had once tended those of the gladiators, but the pay was much better. He also continued to write. Or maybe it is better to say he continued to speak. He wrote his books by talking. A dozen very busy scribes recorded his every word, words that eventually came to comment, in great and lasting detail, upon the biology of the heart.
When Galen recorded what he knew about the heart, he built on millennia of observations, some of them formal, others part of the sort of everyday understanding of the organ every hunter must have seen beat when he dissected the freshly killed body of his prey. All around the world, hearts had been seen. After an elephant was killed, its ponderous heart was thrown to the ground, a giant house of muscle to be entered through the blood vessels’ wide caves. The tiny heart
s of birds were dried and worn like decoration on strings. Native Alaskans stood beside whale hearts and felt small. One ten-thousand-year-old cave painting in Pindal, near Altamira in Spain, shows a bright red heart inside the body of a mammoth. The hearts of animals were varied and yet recognizable as hearts. They beat the way human hearts would ultimately be seen—in war and accidents—to beat. Even before we knew what the heart did, we knew that it was the measure of a life, be it in a bird, a squirrel, or one’s kin. It sped up in fear, eagerness, or bravery, and when it stopped, the creature that housed it would die. The heart was and is the most deadly place to be stabbed, the most vulnerable lump of muscle, only marginally protected beneath the shallow cage of the ribs. The modern wounds from knife fights are still very often in the heart. Whatever it was, in whatever body it might be found, the heart was simultaneously weak and powerful.3
Just how the powers of the heart were understood varied from place to place. Yet those stories of the heart we know the most about, despite being separated by oceans and time, share many similarities. To the Aztecs, for example, the heart was infused with the sun’s borrowed fire, but that fire had to be returned. To return a bit of fire to the sun, the Aztecs cut the beating hearts of sacrifice victims out of their bodies. The priests who did this cutting (and, as if it weren’t already brutal enough, tearing) would have seen more living hearts than anyone else up to that point in history. They would have known the weight of a heart and many of its specific details. They gathered enormous clay jars full of human hearts that would, at the end of the season, be poured into water, whether cenote or sea, in gratitude for the sun-blessed crops. In the intervening months, the hearts would be placed where they could be observed and contemplated. The result of that contemplation was not recorded; the Aztecs left no comment about what they thought the heart did or why—only that they, like nearly every other culture, regarded it as important. The Aztecs decided to remove hearts, not livers, kidneys, or stomachs, from those who were sacrificed.