Any surgeon who would attempt an operation of the heart should lose the respect of his colleagues.
— T. H. Billroth, German surgeon
It was July of 1893, and the city of Chicago was melting. It was the summer of the World’s Fair, when inventions from around the world began to transform America. By fall, the first hamburger would arrive in Chicago, as would the first machinery for making chocolate commercially and the first tinny version of Alexander Graham Bell’s phone. It was also the summer in which Daniel Hale Williams (1856–1931), a young doctor from the rough side of town, would make the biggest decision of his life.
Williams was born of African American–Scots–Irish–Shawnee parents, but he was viewed by the society in which he lived, the society of Hollidaysburg, Pennsylvania, as African American. Williams’s father died when he was young, leaving his mother to care for him alone. She was sufficiently overwhelmed that she sent Daniel to be an apprentice to a shoemaker in Baltimore when he was just eleven. That might have been the end of the story, except that young Williams decided to go to Wisconsin, where he began working in a barbershop. The store’s owner took an interest in helping Williams finish high school, where he excelled. Then the owner helped him apprentice in medicine, at which he also excelled. Finally, in 1880, the owner helped him apply to the Chicago Medical College at Northwestern University, where he was accepted and where he, once more, excelled. Williams was the first African American student in the program.
In 1883, the new Dr. Williams set up a small practice on Michigan Avenue in Chicago. He also taught anatomy at Northwestern University and worked as a doctor for the City Railway Company and, later, the Protestant Orphan Asylum. He was one of just four African American doctors in Chicago at the time and yet his abilities were so obvious that in 1889, just six years into his career, he was appointed to the Illinois Board of Health. Williams wanted more. He wanted to do something more for the city and himself. He was aware that African Americans in Chicago often received poor care from white physicians and nurses. He also watched as African American doctors and nurses struggled to get training and positions, due to racism in hospitals and universities. The challenges facing young African Americans were not waning. At just this moment, a man Williams knew and respected, the Reverend Louis H. Reynolds, came to Williams asking for his help. Emma Reynolds, the reverend’s sister, had recently applied to various Chicago hospitals to train as a nurse (she was the first African American to attempt to do so), but she was refused by every hospital because of her race. Her story moved Williams. After discussions with the Reverend Reynolds and other community members, Williams decided there was only one thing he could do: he would open a hospital. At that hospital, he would train African American nurses.
The hospital would come to be called the Provident Hospital and Training Association. It was a bold dream, one in which Williams persuaded other doctors, white and black, and even donors to believe in. Donations came from many sources, including both Frederick Douglass and the Armour meatpacking company (which would also supply the hospital with many patients due to injuries workers incurred on the job). In 1891, Williams signed the lease on a three-story, twelve-room red-brick house at the corner of Twenty-Ninth and Dearborn. Its living room was turned into a waiting room, and a small bedroom at the end of a hall would serve as a surgery ward. In its first year, this makeshift hospital trained seven nurses, one of whom was Emma Reynolds. It also treated hundreds of patients.
Nothing was ever easy at Provident Hospital, but the doctors and nurses made do with what they had. They had to improvise, because of a lack of supplies and the fact that, more than other Chicago hospitals, they dealt with a large number of trauma patients. Everything was difficult, but Williams and his team persevered. His was a story of a hardworking man who overcame and the hardworking nurses who helped him.
But elsewhere in the city, events were conspiring to change Williams’s story. James Cornish worked as an expressman, a person charged with the care of packages on trains. The job was a good one, but July 9, 1893, was a bad day. The heat left him soaked with sweat, from morning until six. Worse, the heat did not fade, not even when the sun set. It was the kind of heat that called for a whiskey, which is just what Cornish proceeded to order that night at his favorite saloon. While others in Chicago sampled the best of the world at the White City, as the World’s Fair had come to be called, Cornish settled in across town from the fair, among friends. He got his whiskey, took a sip, cracked a flirty joke to the waitress, and walked over to play poker with two friends who were already seated. He felt lucky. A song called “Daisy Bell” was playing loudly from the jukebox. He bounced a little as he walked, eager to laugh, wager, needle his friends, and laugh some more. Then things changed irrevocably.
The sounds around Cornish grew louder. Noise rose like dust. A fight had started. A chair was smashed over the bar. Punches began to land against sweat-damp bodies. Cornish stood on his toes to watch, and then suddenly he was in the scrum. A knife appeared. The man with the knife lunged toward Cornish and stabbed him in the chest. The man pulled the knife back out, someone screamed, the crowd dispersed, then sirens started and several women bent toward Cornish’s body, which now lay on the ground.
An hour or so later, at Provident Hospital, Cornish was laid outon a stretcher. His clothes were soaked with blood. He was wheeled into an operating room, where the nurses and Daniel Hale Williams gathered around him. To Williams, Cornish’s wound, about an inch in diameter, looked as though it might be superficial. But its location, just to the left of the breastbone, was worrisome. Without x‑rays (they were to be discovered two years later, in 1895), there was no way of knowing how deep the wound might be or whether it had reached the heart. The only diagnostics available to Williams were ancient ones. He could feel Cornish’s pulse. He could listen to his breathing. He could also put his head or, if he could afford one, a wooden stethoscope to Cornish’s naked chest and listen for its wild sounds.
Initially, apart from the hole in his chest, Cornish seemed okay. His pulse was normal. His heart beat. He was cleaned up, sewn shut, and left to rest overnight. Cornish slept in a bedroom with a window that looked out across the city. He had not yet had a chance to inspect his surroundings. He was too weak and then too tired. Warm air blew through the curtains over him. Within hours, his condition, which had seemed stable, began to deteriorate. Dr. Williams was called back in. He ran to the room and up to Cornish’s side, where he put his ear to his chest. Cornish’s heartbeat was weak, and then, as Williams listened, it seemed to disappear entirely. The heart was still beating, but faintly. On July 10, Williams concluded that the knife must have penetrated more deeply than he had initially thought — all the way into the heart.
A knife to the heart can wreak havoc, though the precise sort of havoc depends on the details of where and how the knife enters. The heart has two sets of pumps. Together, the left atrium and left ventricle make up one; the right atrium and right ventricle the other. Each atrium (from Latin for “hall or court, a gathering place”) sits atop its corresponding ventricle. When the left atrium contracts, it gently squeezes blood into the left ventricle. The blood does not need much of a push, as it is moving from an area of high pressure into one of low. All it needs is a little nudge. The left ventricle then contracts much more forcefully, sending blood throughout the entire body, down the arteries, to the arterioles, and then through the six hundred million capillaries, each tube of which is just a single cell wide. The force of the left ventricle’s contraction would be sufficient to push water five feet up into the air or, as is the need in the body, to push blood through the more than sixty thousand miles of blood vessels in the human body.
At the same time that the left atrium and then left ventricle contract, something similar happens in the right atrium and then right ventricle, except with less force because the blood leaving the right ventricle does not need to go through the whole body. It needs only to find its way to the lungs, where capillaries rest on three hundred million air sacs, and hemoglobin, in red blood cells in the blood, releases carbon dioxide and gathers oxygen.
The sounds of the heart, at least the most conspicuous sounds, are those of the valves between the atria and ventricles (the mitral on the left; the tricuspid on the right) closing when the ventricles contract (and, in doing so, preventing blood from flowing back into the atria) and then, more loudly, the valves between the ventricles and the arteries (the aortic on the left, the pulmonary on the right) closing once the ventricles have finished contracting (which prevents blood from flowing back into the ventricles): lub- dup, lub- dup. The sound of the heart is the closing of these valves, day in, day out, billions of times in a fortunate human life.
So much depends upon the heart’s pumps. The blood that is pumped out of the left ventricle travels into the aorta, which serves as a superhighway from which blood is shunted off into branches to the arms and brain, to the internal organs (intestines, liver, kidneys), and to the legs and genitals. Meanwhile, the right atrium and ventricle receive the blood that has come back in a different form than it went out — now the blood is depleted of oxygen and full of carbon dioxide. This “used” blood is pumped to the lungs (via the pulmonary circulation; pulmo- comes from the Latin for “lung”), where blood cells, in effect, exhale carbon dioxide and inhale oxygen. The oxygenated blood then flows to the left atrium, where the process begins again.
All of this is happening in you right now. It happens in waves: contraction, relaxation. The contraction is referred to as systole (from the Greek for “to pull together”), the relaxation, diastole (from the Greek for “to separate”). Hold your hand to your neck, and you can feel, in the expansion and relaxation of your carotid arteries (which supply your brain with oxygenated blood), the consequence of your heart’s pumping.
That is what you hope for, anyway, but when Williams felt his patient’s neck, that is not what he found. The assault on Cornish’s internal machine had made the heart both weak and slow, and the pulse could barely be felt. A knife wound can provide a new hole through which blood pours into the body cavity instead of into arteries. It can also — and this is far worse — interrupt the ability of the heart to contract.
Just what was happening in Cornish’s body was hard to say. Today we would have many more clues than Williams had. We could look at an x‑ray, a sonogram, a CT scan, or an MRI. A catheter might be threaded into a patient’s heart to release dye that would reveal, in the x‑ray, the location of the damage. A machine would record the rhythm of the heart. What we would know today would not be perfect, but it would be useful. Williams had virtually nothing except the weakening of Cornish’s heartbeat and his obviously deteriorating condition.
The weakening of a patient’s heartbeat might be due to a problem in the heart itself, but it might also be due to loss of blood, to which, we now know, the body can partially respond. The arteries in our bodies are muscular. They contain a layer of smooth muscle. Smooth muscle is not under our conscious control, but it is under our bodies’ unconscious, autonomic control. The muscles in our arteries do not push blood along — that is the heart’s unique role — but they can widen or narrow the vessels to slow or speed up its passage. And one sort of artery, the arteriole, can actually stop the flow of blood. Arterioles are the narrowest arteries — they meet up with the capillaries, which then connect to venules, which in turn connect to the veins that carry the oxygen-depleted blood back to the heart — and arterioles are narrow enough that when they contract, they close. They do so to influence the flow of blood in the body. When your fingers are cold, blame the arterioles, but also thank them because they are, based on the condition of your body, helping to move blood where it is most needed.
If Cornish was losing blood, the arterioles would have begun to shut off the flow through nearly all of the capillaries in the body (except those in the three organs that never, except in the very worst circumstances, lose their blood flow: the brain, the heart, and the lungs). When this happens, the pulse weakens, the extremities grow cold, and the body struggles to preserve that which it cannot do without.
With his patient deteriorating, Williams had to make a decision. He knew Cornish’s heart was broken, but he was at a loss to say precisely how or why. No matter the cause, the most likely scenario seemed to be that Cornish, friend to many, son to one good mother, was about to die.
Knife wounds to the heart were remarkably common in 1893. They remain common today, though they are now rarely fatal. If you are stabbed in the heart, raced to the hospital, and operated on, you stand about an 80 percent chance of survival. A trauma to the heart can be operated on in any of a variety of ways, or not operated on at all, depending on the condition of the heart. The odds are now good for victims of stabbings, thanks to both technology and the learned skills of surgeons. But in 1893, the most likely consequence of a stab wound to the heart was death. Once the heart started to bleed, whether from a stab wound or some other assault, a patient depended purely on fate to survive, a kind of cardiac destiny. Sometimes the body was able to restrict blood to the core and heal the wound before too much blood was lost. More often, it couldn’t. Infections took over, or the heart lost its rhythm. Doctors sought medicines that might cure such wounds, but they sought in vain. And no doctor in the world was known to have successfully operated on a heart, wounded or otherwise. No one, as far as Williams knew, had even tried. It was the Mount Everest of the body, the great mountain not yet climbed. Yet, if Williams was anything, he was the kind of man who tried, the kind who might scale a mountain to save someone. He had tried working on shoes as a young man. He had tried working in a barbershop. He had even tried music and law. He had tried surgery and running a hospital. Now, on July 10, one day after Cornish was stabbed, he would try something even more novel.
* * *
Williams and the nurses looked down on Cornish. They all bent over him to closely inspect the damage. It seemed likely that his heart — that bloody engine — was torn, though even that was not entirely certain. If it was torn, Cornish would die from internal bleeding or, depending on the severity of his wound, heart failure. Williams could do what every other doctor in the same situation had done for the past ten thousand years, which was walk away. Or he could operate. Whatever he did, the heart was there, just inches from his face as he bent over his patient, just under the surface and yet for all of time so very far away.
One can imagine the sort of person it takes to perform the first surgery ever on a heart. He or she would need to be self-confident but also eager to go beyond what had been done, both to save a patient and to advance humanity. Williams was such an individual. On July 10, 1893, the operation began. Williams was handed a scalpel and the other tools necessary to cut into Cornish. He was about to attempt a feat surgeons all over the world had advised was too dangerous and immoral. Success or failure, Williams was about to make history.
The human heart beats, on average, about a hundred thousand times a day, pumping 7,500 liters of blood through arteries and veins. But this was no average day. On this day, Williams’s heart would have rabbited along, pushing extra oxygen to his eager brain. Six other doctors had also gathered in the room. Williams swore he could hear their hearts too. This is the great irony of surgery and, more generally, medicine: that a doctor in one body bends to mend a patient in another body, the doctor relying on the same parts (her heart, her brain, her skin and flesh) she aims to fix in her patient. The room was more than a hundred degrees, and even before Williams began, everyone was sweating. Now, with anxiety and adrenaline, they were dripping so much that the floor was wet. Williams wiped his head and then, with the nurses at his side, inserted the blade into Cornish’s wound and cut a six-inch incision. He inserted his right hand through the incision and pulled one of the ribs away from the sternum to make a hole, a kind of window through which he could look at Cornish’s heart. He siphoned away the excess blood and, for the first time, had a clear view of the heart. In general terms, it was an ordinary heart, somewhat larger than a clenched fist, about five inches long, three and a half inches wide, and two inches thick. What was not ordinary was that it lay bare, as naked as a heart can be, suddenly at the mercy of insight, skill, and luck.
The atria and ventricles of the heart are surrounded by the pericardium (the word comes from peri-, Greek for “around,” and cardia, Greek for “heart”), a smooth, oily sac. As Williams looked at Cornish’s pericardium, he could see where the knife had gone in, through the pericardium and into the heart muscle. Williams had very little time to decide what to do. It was too late to turn back. As
he looked at the heart muscle, it seemed as though the wound had sealed itself over, closed with the pressure of the contractions of the heart. Right or wrong, this observation, along with perhaps a hiccup of trepidation, led him to focus on the pericardium. He would not be the first to operate on the heart muscle, but he would be the first to sew the pericardium. He cleaned the wound as best as he could (antiseptics were new and one of the reasons Williams had a chance, albeit relatively slight, of preventing infection) and then began to sew with catgut thread. The needle sank through the pericardium and then, with a tug, came back out the other side. It sank again. As it did, the heart beat, though only weakly. Williams tried to time his efforts with the heartbeat. The hope was that the stitched-together pericardium, however flimsy the sewing, would stabilize the heart. When he was finished, Williams took a deep breath and stepped back to inspect his work. Without meaning to, he beamed a little. Time would tell if Cornish would live to beam back, but whether the patient lived or died, Williams had just changed the trajectory of medicine. He had taken the plunge into the heart. Others would follow. They would not be able to resist the temptation to raise their scalpels and, one heart after another, cut.
Williams worked a little over a hundred years ago, just yesterday in the context of the human story. The history of surgery is ancient. Stone Age needles were once used to suture cuts in pre-agricultural Africa. Army ants were used to close wounds in India and the Americas (the ant bit down on the wound and its jaws locked tight; one ant for small lacerations, two for big ones). As societies became larger and more sophisticated, the surgical repertoire expanded. With the birth of agriculture came civilization, writing, and systematic attempts to create new forms of medicine. In ancient Mesopotamia, China, and elsewhere surgeries were attempted on many different parts of the body, even the brain. As early as eight thousand years ago, medicine men chanted, burned herbs, and then drilled holes into people’s skulls to “relieve pressure” (at one site in France, dated to 6500 BC, one-third of skulls showed evidence of drilling). Many of these surgeries were successful, or at the very least not fatal. Amputations were also done, as were removals of stones from bladders. With time and a kind of mortal inevitability, more and more parts of the body came to be operated on, until, at the time of Cornish’s incident — roughly eight thousand years into the history of surgery — someone somewhere had either effectively or experimentally (or both) operated on nearly every single part of the body. The brain, eyes, arms, legs, and stomach had all been cut and sewn, but not the heart.
The heart was special. Before 1893, for the thousands of years during which humans practiced medicine, the heart was viewed as either functionally or philosophically untouchable. The standard medical text in Williams’s office (a converted bedroom closet) offered this: “Surgery of the heart has probably reached the limits set by Nature to all surgery; no new method, and no new discovery, can overcome the natural difficulties that attend a wound of the heart.” Any doctor who dared operate on the heart would be shunned and, many thought, should be. Theodor Billroth, a dominant force in European surgery at the time, argued that a surgeon who tried to suture a heart wound deserved to lose the esteem of his colleagues. Williams had crossed the last anatomical frontier.
Several factors contributed to the perception of the heart as inviolable. Many cultures had long viewed the heart as the source of emotion, the mind, and the soul. Such sentiments persisted in the late 1800s. The French surgeon Ambroise Paré gave them voice when he wrote, “The heart is the chief mansion of the soul, the organ of vital faculty, the beginning of life, and the fountain of the vital spirits . . . the first to live and the last to die.” The modern Valentine’s Day link between the heart and love relate to these ancient concepts echoed by poets across centuries in both their words and their deeds. Take the death of Percy Bysshe Shelley. Shelley was cremated, but, according to his friends, his heart did not burn, so powerful was its poetry. While doctors practicing in the late 1800s had a less mystical interpretation of the heart’s function than Shelley’s friends, they still imbued the heart with a kind of unknowable magic, the sort we now seem to reserve for the brain. Who could really say what lurked in its dark caves? If not Sirens and Fates, it held at the very least the essence of life.
The taboo associated with operating on the heart deterred many doctors. But if that were the only problem, some bold surgeon would have violated it long before Cornish ended up on the table. The field of surgery has long attracted and trained (albeit not exclusively) aggressive, overconfident individuals who do what seems impossible rather than what is allowed. The real challenges were technical problems in the art and science of surgery. The heart beats. It is the most lively part of the body, wild and hopping, so any operation would have to be done in time with the beating, as though in a sort of dance, a surgical waltz. Antibiotics had not yet been discovered, so the odds of infection were high. Nor did x‑rays exist (much less angiograms and CT scans), so no one could see what was wrong with the heart until the chest was opened. Then there was the issue of breathing. No machines existed for keeping airways open during surgery. For all of these reasons and more, every time someone with a bullet or knife wound to the heart came into a hospital anywhere in the world, the only option was to keep an eye on the patient and watch as the body healed itself or, as was often the case, did not.
* * *
Thirteen days after his surgery, Cornish, who was still in the hospital, had his fate announced to the world. He had survived. In the newspaper articles that followed, Cornish was described as a fortunate soul, Williams as a hero. Williams was heralded as the first surgeon to have operated on the human heart, and successfully at that. Williams was not modest about the procedure. He would go on to do others and even brag when he did; as he would say of himself in a newspaper article, “Successes crowned [his] attempts in nearly every case.” Meanwhile, Cornish was still in the hospital, where, suddenly, on August 2, he got worse.
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.
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. 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 successful 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). 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.
Excerpted from "The Man Who Touched His Own Heart" by Rob Dunn. Copyright © 2015 by Rob Dunn. Reprinted with permission of Little, Brown and Company. All rights reserved.