The Man Who Touched His Own Heart Page 2

  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 out on 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),5 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.6

  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 (LA in the figure) and left ventricle (LV) make up one; the right atrium (RA) and right ventricle (RV) 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.

  The heart, with key parts of its geography indicated. (Courtesy of ilbusca/Getty Images)

  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,7 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.