INTRODUCTION

A few months ago I was walking through a large teaching hospital with one of the consultants, a surgeon of some eminence, when he turned to me and asked: ‘Why do you want to write a book about heart surgeons? We’re all psychopaths.’

Although tempted to reply, ‘Precisely because you’re all psychopaths,’ I just laughed; while this affable man had an impressive ability to monopolise any conversation, I was pretty sure he was no psychopath. And after spending many hours in the company of cardiac surgeons, both in their operating theatres and in more unguarded moments, the one thing that struck me about them was how difficult they were to pigeonhole. True, I’d met one or two who spoke fluently and with a startling lack of modesty about their own achievements, deftly sidestepping any questions that threatened to take us into neutral territory. But others were diffident almost to a fault, more comfortable talking about their mentors and patients than about themselves. Then there were those who were simply fascinated by the minutiae of their craft, happily explaining techniques and procedures to me at length until an exasperated secretary put a head round the door to shoo them off to a more important engagement. Most seemed to be normal and well adjusted – more blessed with self-confidence than most of the population, perhaps, but also friendly and compassionate, and manifestly devoted to helping their patients get better.

So at first I dismissed the surgeon/psychopath association as a self-deprecating joke. But why had he said ‘psychopaths’? ‘Egotists’ or ‘narcissists’ would have been just as funny, and probably more accurate, I thought. And then I stumbled across a study in the Bulletin of the Royal College of Surgeons of England which asked simply: ‘Are surgeons psychopaths?’¹ The authors assessed 172 doctors for the traits typical of psychopathy, including ‘Machiavellian egocentricity’, ‘social potency’ and ‘cold-heartedness’. Surgeons scored particularly highly on this scale, exceeded only by paediatricians in their psychopathic tendencies.^fn1 The most commonly identified personality traits in surgeons were stress immunity and fearlessness – qualities which, the researchers noted, are ‘beneficial or even essential’ when providing care in difficult situations.

Not long afterwards I spent a day in the operating theatre of Marjan Jahangiri, a charismatic surgeon based at St George’s Hospital in Tooting. Standing next to the anaesthetist at the head of the table, I had the best possible view as Professor Jahangiri prepared to replace a diseased heart valve. The first part of the procedure had already been completed, the patient’s chest lay open and I could clearly see his motionless and empty heart, temporarily relieved of its work by the heart-lung machine a few feet away, which was now oxygenating his blood and circulating it through his body. Professor Jahangiri picked up a pair of scissors and in one smooth motion severed the aorta, the artery that normally carries oxygenated blood from the heart to the rest of the body. Involuntarily I took a large gulp of air: I was taken aback by the insouciance with which she had cut the heart loose from its moorings, somehow transforming it from an integral part of the human machine into a distinct and isolated viscus.

Why was this moment so shocking? It was only later, as I watched her replace the man’s diseased aortic valve and then reconstruct his aorta with a tubular graft of synthetic fabric, that I understood. It was the point at which there could be no turning back, when the patient became entirely reliant on the skill of an experienced surgeon to ensure that he left the operating theatre alive and with his heart beating once more. Only somebody with absolute confidence in their abilities could pick up those scissors and be happy to continue. This, I realised, was the fearlessness that all cardiac surgeons need in order to do their job.

Every contemporary heart surgeon has lost a patient, and all need to confront the sobering fact that a single mistake may be all that separates life and death. But the truth is that cardiac surgery today is safer than it has ever been: there is a wide repertoire of operations which have become routine, and so safe that the vast majority of patients make an excellent recovery. Many surgeons walk into theatre expecting every patient to pull through; it is the rarity of death that makes it all the more shocking. So what must it have been like to be a member of the profession in the early years, when death was not merely an occasional visitor but the cardiac surgeon’s constant companion?

Surgeons were so convinced of the unique fragility of the heart that they scarcely dared touch it until the last years of the nineteenth century. The first successful operation on the beating heart took place in 1896, but for almost forty years the only interventions possible would remain simple suture repairs for stab or bullet wounds. Specialists were sure that the scalpel would one day provide relief from many other cardiac conditions – and they were right – but achieving that progress took many decades and entailed a shocking loss of life. The only way of establishing the efficacy of a new procedure was to test it on a patient, and the few plausible candidates for such experimental surgery would usually be so sick that their death was likely whatever happened. For some new operations, therefore, surgeons were braced for the possibility that few, if any, of their patients would make any sort of recovery. And it was not just human lives at stake: virtually every major cardiac procedure was first tested on rabbits, dogs, apes, calves or pigs, many thousands of them – indeed, far more experimental animals died during the twentieth century than did patients.

Pioneers in such a brutal field required perseverance and an extraordinary degree of emotional resilience. Unsurprisingly, many of those attracted to this unforgiving occupation were powerful characters, with strong opinions and unshakeable faith in their own abilities. This was a true medical elite: it is easily forgotten that fifty years ago heart surgeons were the most glamorous and best paid professionals in the world, celebrities who were photographed for the cover of Time magazine and became the friends of royalty and film stars. Some made colossal fortunes which they spent on property empires or fleets of luxury cars; others donated their considerable surgical income to the hospitals for which they worked. Many were tyrants, impossible men who worked seven days a week and expected the same of their juniors, and bitter rivalries were commonplace. And they were usually men: for years this was an almost exclusively male club, a bastion of inequality which did not begin to admit women in significant numbers until the turn of the millennium.

Much else has changed. If cardiac surgeons were quasi-deities in the 1960s, it was partly because there were so few of them, a select number willing and able to tamper with an organ traditionally seen as the repository of the soul. Today there are close to fifty centres of cardiac surgery in the UK alone, and every developed nation has hundreds or even thousands of highly trained surgeons. There is no longer such mystique surrounding the profession, and (with few exceptions) the surgeon has willingly stepped down from his pedestal. In some hospital departments, treatment is now overseen by a multi-disciplinary ‘heart team’, in which anaesthetists, surgeons, cardiologists and medical-imaging specialists all play an equal role, and discussion of a case may only take place if the patient is present.² The dictator has become a member of a democratic assembly.

Though the body count in this story is high, it is also full of unexpected recoveries, exhilarating moments of discovery, and celebrations of human ingenuity. Its heroes and heroines are not just those who held the surgical instruments, but also the armies of nurses, physiologists, engineers, biochemists and inventors who made their work possible; and of course the many patients, and their families, who willingly allowed their bodies to be used as glorified laboratory specimens. This is not a comprehensive history of the subject, and I have had to be highly selective in which operations and individuals to include; many other important contributions were made which, with regret, I was unable to acknowledge. At times progress was driven by competitive individuals, at others it was a team effort; but what they achieved was miraculous, and I hope readers will share my admiration for these brave pioneers.

1. BULLET TO THE HEART

Stowell Park, Gloucestershire, 19 February 1945

A few minutes’ drive south of the pretty market town of Northleach, in the heart of the Cotswolds, is a pub called the Inn at Fossebridge. If you park here, as I did one blustery spring afternoon, and climb a steep hill, you’ll soon come to a small wood that lies beside a Roman road, the Fosse Way. It’s a peaceful spot filled with birdsong, and as you tramp through the undergrowth it seems scarcely possible that this was the scene of one of the great feats of modern medicine. But seventy years ago this unremarkable little wood was the birthplace of modern heart surgery.

The trees, although tall, were planted only a few decades ago, and beneath them some relics of what used to be here are still visible. Dozens of low brick structures protrude through a light covering of moss and dead branches: these are the bases of long-demolished Quonset huts,fn1 and just off the footpath I found one still intact, preserved – or so I hoped – as a reminder of what happened here in wartime.

In late 1944 you would have seen lines of these huts, hundreds of them, covering several acres of the Stowell Park estate. This was a huge military hospital, with its own airstrip, constructed in haste to cope with the flood of casualties expected to follow an Allied invasion of continental Europe. In April that year it became the headquarters of the 160th General Hospital of the US military, a unit specialising in chest injuries which at its peak had 500 patients under treatment¹ – and in an improvised operating theatre in one of these huts, a young Iowan surgeon called Dwight Harken removed bullets and shell fragments from the chests of 134 soldiers without experiencing a single fatality.² This was impressive in itself, but what makes his unblemished record all the more remarkable is that he extracted many of these pieces of twisted metal from inside a beating heart.

A metal hut is not the ideal environment for heart surgery. Sixteen feet wide by twelve high, Harken’s ramshackle operating theatre had a roof of corrugated iron and was poorly insulated: the summer sun turned it into a stifling furnace, while in winter it was heated by a small stove. But the cold was the least of his concerns as he prepared for surgery on 19 February 1945. He already knew his patient well: Leroy Rohrbach, an infantry sergeant who had been involved in the Normandy landings the previous summer, a tricky case who had been in Harken’s care for some time. A month after D-Day he had been caught up in the fierce fighting which obliterated the town of Saint-Lô, and an exploding shell had sent a piece of shrapnel through the lower part of his chest.

He was evacuated to England, where an X-ray showed a small piece of metal lodged inside his heart. On the fluorescent screen it could be seen pulsating gently with the throb of his heartbeat, indicating that it had passed through the outer wall of the organ and was now inside one of the cardiac chambers. On 15 August Harken operated and came desperately close to removing it: after making a small incision in the heart he managed to grasp the metal fragment with a pair of forceps, but it was jerked from his grasp as the organ contracted, and slipped back into the bloodstream. He made frantic attempts to find it, but it had vanished from view and could not be felt through the heart’s thick walls. Three months later he tried once more. Again he found it; and again it defied him, slipping from his forceps just as success seemed assured.

Yet despite these failures his patient continued to improve. This was not unheard of: soldiers with similar injuries might never need an operation, living quite happily with pieces of shrapnel – or even bullets – inside them as permanent reminders of their military service. The sergeant showed no signs of infection, and electrocardiograms revealed that his heart rhythm, which had been disturbed by the injury, was slowly returning to normal. Given that his patient had already endured two major and fruitless operations, Harken was reluctant to risk a third: it would be dangerous and possibly unnecessary.

But there was another consideration. Although many soldiers lived active lives after such injuries, others developed crippling anxiety about the alien shard of metal lodged deep inside their chests. They became depressed, fretful, and lived in perpetual fear of sudden death, terrified that a single careless movement could be enough to dislodge the shrapnel and kill them. This phenomenon was well known by 1945, and had been given a name: cardiac neurosis. Indeed, Harken’s patient had become increasingly nervous about the inch-long shell fragment inside his body and begged the surgeon to persevere. Appreciating that such distress constituted a significant clinical consideration, Harken agreed to make a final attempt.

At thirty-four, Dwight Harken was already one of the most highly regarded surgeons in the US medical corps. A tall and muscular redhead, he had been born into medicine, delivered by his father, a doctor who ran the small Harken Hospital in Osceola, Iowa, and had grown up in a basement flat in the building. During his childhood the antiseptic smell of the wards had never been far away, and his father’s hope was that he would eventually take over the family business; but small-town life had little appeal, and he left to study at Harvard. A few years later he moved to Britain to work with the country’s leading chest surgeon, Arthur Tudor Edwards, at the Brompton Hospital in London.³ During the war Tudor Edwards had an immense impact on military medicine, training surgeons and developing new techniques in his treatment of air-raid casualties. Given this pedigree, and despite his youth, Harken was a natural choice to run the new specialist thoracic unit in Gloucestershire.

Although Harken’s operating theatre was little more than a shack, he was otherwise in a fortunate position. By February 1945 he had state-of-the-art equipment and drugs, including the new antibiotic penicillin, and a close team of surgical colleagues who had assisted him in over a hundred operations. Charles Burstein, the anaesthetist, had been with him since the beginning;⁴ he now put the patient to sleep, administering a mixture of ether and air through a facemask. Today the hut was more than usually cramped. Word had got around about this remarkable young American doing wondrous things in a field in Gloucestershire, and a delegation of eminent British surgeons, including Tudor Edwards, had come to watch Harken at work. Above the operating table a cameraman was lying on a scaffold, ready to film proceedings for the benefit of medics in America.⁵

The sergeant’s body bore obvious scars from the first two operations, one a snaking line across his back from shoulder blade to hip, the other a smaller curve around his left nipple. Harken chose to renew his attack through the chest, using a scalpel to reopen his earlier incision. With a pair of Tudor Edwards retractors, an instrument named after his mentor, he separated the patient’s ribs and exposed the heart by cutting through the pericardium, the tough sac around it. He could see the scar in the cardiac wall left by his first operation, and elsewhere the tissue appeared flabby and discoloured, evidence of trauma. By gently squeezing the beating heart he was able to locate the foreign body, a small area of hardness in the right ventricle, near the organ’s base.

Now the shell fragment had been found, the delicate task of removing it could begin. Harken held it in place with a finger placed firmly on the outside of the heart, while inserting two rows of catgut sutures on either side, an otherwise straightforward procedure rendered more difficult by the constant contraction and relaxation of the muscle. In the event of catastrophic bleeding these could be pulled together, a simple but effective way of staunching the flow of blood. As Burstein watched the electrocardiogram nervously, looking for signs that this manipulation was disturbing the heart’s rhythm, Harken’s assistant picked up the loose ends of the catgut and waited for a signal. This was the critical moment.

Working as quickly as he could, Harken now made a small incision in the heart wall and inserted a pair of forceps to widen the opening. Through this aperture he introduced a clamp and fastened it around the elusive piece of metal. For a moment all was quiet. And then, as he related in a letter to his wife, ‘suddenly, with a pop as if a champagne cork had been drawn, the fragment jumped out of the ventricle, forced by the pressure within the chamber. Blood poured out in a torrent.’⁶ His assistant pulled the control sutures taut, but the wound continued to bleed. Harken put a finger over it, and picking up a needle started to sew it shut. The opening was closed, but when he tried to remove his finger he discovered that he had sewn his glove to the wall of the heart. Finally his assistant cut him loose, and the job was done. Opening the heart, removing the shell fragment and repairing the incision had taken three minutes. His distinguished guests were deeply impressed: this was surgery of a sophistication and audacity which none had seen before.

Some of Harken’s operations were still more dramatic. Sometimes when he cut into the heart the resulting jet of blood entirely obscured his view, and he was forced to fish around blindly for the metallic fragment in a churning scarlet sea. The degree of haemorrhage was often so severe that patients had to be given rapid transfusions. Today, blood comes pre-packed in plastic bags which are hooked on a drip stand, and enters the body under atmospheric pressure; in 1945 the blood bag had yet to be invented, and so it was instead poured into a bottle into which air was then pumped to create the high pressure necessary to force it into the patient’s veins. Most of the time this worked without any problems, but every so often the bottle would explode, showering the entire operating theatre and its staff with blood and shards of glass.⁷

On another occasion Harken tried a novel method of removing foreign objects. During the First World War several surgeons had realised that since many bullets were made of iron it should be possible to remove them magnetically. Harken took up this idea, ordering a huge mains-powered electromagnet which was mounted above the operating table. After the patient’s chest had been opened it was turned on. The bullet remained stubbornly in place, but every surgical instrument in the room flew lethally through the air and landed on the surface of the electromagnet with an alarming metallic clink.⁸

In an age when open-heart surgery takes place in thousands of hospitals all over the world every day, it is difficult to appreciate quite what a momentous achievement Harken’s work was. He was not the first to remove bullets from the heart, but never before had a surgeon operated on so many patients without a single death, or made a terrifying procedure look almost routine. The magnitude of the accomplishment is noted in the official account of British surgery in the Second World War: ‘His outstanding success, his daring interventions, and his brilliant results underline one of the most striking chapters of surgical achievement in any war, and in a symposium of this type all British surgeons will unite in offering their tribute to him.’⁹

Such hyperbole is easier to understand if you consider that less than half a century earlier heart surgery was widely regarded as impossible. In 1896 the author of the most widely read British textbook on chest surgery, Stephen Paget, wrote, ‘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.’¹⁰ One of his contemporaries, the American Benjamin Merrill Ricketts, observed gloomily that ‘there is probably no organ or disease about which so much has been said and written, with so little accomplished, as the heart with its diseases.’¹¹

By the end of the nineteenth century surgery had made great strides, thanks to two recent discoveries: anaesthesia and antisepsis. The first anaesthetic agents, ether and chloroform, were discovered in the 1840s and made it possible to undertake quite radical procedures without inflicting excruciating pain. Twenty years later Joseph Lister showed that if instruments and dressings were sterilised, infections could be prevented, and the age of modern surgery had begun. It was now possible to operate at leisure on an unconscious patient, and to be reasonably confident that they would not then succumb to gangrene.

Progress was rapid. Within a few decades surgeons were operating on virtually every part of the human body. By 1890 detailed surgical textbooks were available for the skeleton and its muscles,¹² the mouth and jaw,¹³ the ear,¹⁴ the eye,¹⁵ the kidney,¹⁶ the reproductive organs,¹⁷ the urinary system,¹⁸ the intestines¹⁹ and the rectum.²⁰ Not even the brain was out of bounds: in 1884 Rickman Godlee successfully removed a tumour from inside the skull of a twenty-five-year-old man in an operation in London, prompting editorials in national newspapers.²¹

So why was the heart, alone among the major organs, still taboo? There were certainly practical difficulties: its position beneath the ribcage made it inaccessible, and operating inside the chest could cause the lungs to collapse as air entered the space around them, causing catastrophic respiratory failure. And then there was the fact that if the patient were to remain alive the heart had to keep pumping: how could you possibly operate on an organ that wouldn’t stay still?

But there was something else, too: a reverence for the heart rooted in centuries of tradition. It was not merely another organ, but an object far more mysterious and freighted with significance. This was eloquently expressed in the sixteenth century by the French surgeon Ambroise Paré, who described the heart as ‘the chief mansion of the Soul, the organ of the vitall faculty, the beginning of life, the fountain of the vitall spirits’.²² This attitude is even apparent in the oldest surviving medical texts, those from ancient Egypt. The heart was then believed to be the seat of the intelligence, the emotions and the soul, and was preserved after death: admission to the afterlife could only be granted when it had been weighed by the god Anubis. Later, Greek scholars agreed on the fundamental importance of the heart. In the fourth century BC Aristotle pointed out that it was the first organ to form, and the last to die; it occupied a central position; it moved; and it communicated with all other parts of the body. He also saw the heart as the source of the ‘animal heat’, the life force inherent to all organisms.²³

Given the fundamental importance assigned to the heart by early thinkers, it was natural to assume that injuries to it must necessarily be fatal. In his great 37-volume encyclopaedia Natural History, compiled in the first century AD, Pliny described the heart as ‘the primary source and origin of life’. He claimed that it ‘is the only one among the viscera that is not affected by maladies, nor is it subject to the ordinary penalties of human life; but when injured, it produces instant death’.²⁴ A century later the most celebrated surgeon of the ancient world, Galen, was able to describe the effect of cardiac injuries at first hand. For a few years he was the official doctor to the gladiators of his hometown of Pergamon, and witnessed many die from the effects of a stab wound to the heart. He noted that such a death was often instantaneous, but that the length of survival depended on the location of the wound:

When a wound pierces the ventricle of the heart, they die immediately with great flow of blood, and especially so if the ventricle of the left part has been wounded; but if it does not reach the ventricle, but the wound stops in the substance of the heart, some of those affected can survive not only the day on which they were wounded but as long as the following night.²⁵

Galen’s writings remained the foundation of medical education until superseded by Renaissance scholarship almost 1,500 years later, so it is unsurprising that his conclusions went undisputed for centuries. In a wince-inducing treatise on the treatment of wounds, the seventh-century Byzantine physician Paul of Aegina gave a vivid description of a cardiac injury and its fatal consequences: ‘When the heart is wounded, the weapon appears at the left breast, and feels not as if in a cavity, but as fixed in another body, and sometimes there is a throbbing motion; there is a discharge of black blood if it can find vent, with coldness, sweats … and death follows in a short time.’²⁶

That description was echoed eight hundred years later by Paré, the greatest surgeon of the Renaissance. Like Galen he had seen such injuries for himself, having spent many years as a military surgeon on the battlefields of France: ‘If the heart be wounded, much blood gusheth out, a trembling possesseth all the members of the body: the pulse will be small and weak: the colour of the face will become very pale: a cold sweat, and frequent swooning will assault the wounded party: and when the limbs grow cold, death is at the door.’²⁷ But Paré also pointed out that death was not necessarily instant. He had witnessed a duel in Turin during which one of the combatants had been stabbed through the left breast; he nevertheless continued to fight, chasing his enemy for two hundred paces before falling down dead. When Paré examined the body he found a wound in the heart so large that he could insert his finger into it.²⁸

Yet by the end of the sixteenth century surprising discoveries were being made which threatened to challenge the dogma that cardiac wounds were inherently fatal. Barthélémy Cabrol, physician to the French king Henry IV, described conducting an autopsy on two men and finding scars on their hearts. One had ‘a lesion the size and width of a myrrh leaf, which penetrated quite deeply; and lest anybody think that these injuries were the cause of death, both men had been hanged: one for thieving, the other for producing counterfeit coin’.²⁹ Still more perplexing was the discovery of Johann Dolaeus, who wrote of a ‘bullet of lead found in the heart of a boar, covered with flesh, that no way endangered his life: for he was a large boar, and when it was taken out with a huntsman’s knife, any one might observe that the wound was not made two or three days, but a long time before’.³⁰

Though many physicians continued to insist that cardiac wounds spelled death, the body of evidence to the contrary continued to grow. In 1778 Henry Thomas, a marine on board HMS Foudroyant, slipped off a gangplank while the ship was in dock at Portsmouth and fell on his bayonet. He removed the blade and declared himself fit to resume his guard duty, before collapsing in a faint. He died nine hours later, and when they opened his body doctors were amazed to find that after impaling his colon and liver the bayonet had passed right through his heart.³¹ A few years later a similar injury was seen at the same hospital in Gosport; in this case the soldier survived for two days, but died suddenly while defecating. At a post-mortem the surgeon concluded that a clot had formed in the wound, blocking the escape of blood from the heart, but had been dislodged as the soldier strained to empty his bowels.³²

Throughout medical history some of the greatest advances in surgical knowledge have been made in the theatre of war. Military surgeons encountered injuries so numerous and terrible that they were tested to the limits of their ingenuity, devising new therapeutic approaches if existing techniques proved unequal to their needs. During the Napoleonic Wars, for instance, the Frenchman Dominique Larrey devised the modern process of triage, prioritising casualties according to the urgency of their condition, and introduced ambulances to the battlefield. His British counterpart George Guthrie, meanwhile, introduced new treatments for gunshot wounds of the legs – in particular, early amputation – that drastically reduced mortality. But one of the most celebrated cases of that conflict was one in which the surgeon did nothing at all.

At the Battle of Corunna in northern Spain in January 1809, a private in the Queen’s Royals, Samuel Evens, was shot in the chest. His comrades carried him off the battlefield and he was put on a troopship back to England. It was crowded with wounded and ill soldiers and the only treatment he received was a plaster, but he was still in a fair condition when taken to hospital in Plymouth a few days later. Evens told the Scottish doctor who examined him, John Fuge, that a musket ball was still lodged in his chest, and begged him to remove it, saying that he was sure it was in easy reach. Fuge inserted a probe into the wound, but it was so deep that the entire instrument disappeared into it, and he abandoned the attempt. Three days later Evens died. His body, when Dr Fuge examined it, contained a huge surprise. The musket ball had ripped through the wall of the heart, leaving an inch-long tear, and had lacerated one of the heart valves. This was a catastrophic injury, and yet the soldier had lived for a fortnight after receiving it. Fuge’s report of the case, illustrated by an engraving of the preserved heart in a jar, was widely circulated in Europe and America – graphic evidence of the resilience of an organ hitherto believed to be uniquely fragile.³³

Several similar cases came to light over the next few years, and doctors were now confronted with the question of how to treat them. From a twenty-first-century perspective, the emergency care received by Victor Janson in 1828 leaves a lot to be desired. Aged sixteen, he had been messing around with a friend in the cellar of his parents’ house, and while play-fighting had stabbed himself with a knife. He felt no pain and assumed he had only cut his waistcoat, but ten minutes later noticed his clothes were covered in blood. He was taken to hospital, where doctors bandaged the wound, put him on his back and bled him. For the next three days they repeated this bleeding at regular intervals. The results were evidently unsatisfactory, because a few days later the therapy was intensified and twenty leeches were applied to his anus. Apparently intent on killing his patient, the doctor then inserted a probe into the wound, whereupon ‘the blood sprung to the height of several feet’. Unsurprisingly, the boy soon died.³⁴

Venesection, bleeding a patient by opening a vein, is one of the oldest therapies known to medicine. It was widely practised in the ancient world, when physicians believed that disease was caused by an imbalance of the four fundamental fluids or ‘humours’ of the human body: blood, phlegm, yellow bile and black bile. According to the humoral system, removing blood was a simple way of restoring the natural balance between the four fluids. By the nineteenth century most physicians had abandoned this antiquated notion, yet many retained an evangelical belief in the powers of bloodletting. It was often used in cases where the heart seemed to be under strain: doctors reasoned that reducing the amount of blood in the body was a simple way to reduce its workload.

Baron Guillaume Dupuytren, who was appointed chief surgeon of the hospital of Hôtel-Dieu in Paris in 1815, was a passionate advocate of venesection, and had no doubt that heart wounds could be survived. He advised treating patients as if the organ had not been injured: doctors should dress the wound, bleed the patient regularly and keep them cold.³⁵ Some took this last measure to extremes, packing the patient in bags of ice and cooling the room to sub-zero temperatures, while in summer they might resort to using a cellar.³⁶ This was intended to depress the circulation and reduce the strain on the heart; but others believed that stimulation was the key to survival. Rather than chilling their patients, they enveloped them in warm blankets and piled hot water bottles all over them.³⁷ There was also little agreement about what they should be given to eat or drink. Baron Dupuytren suggested acidulated drinks,³⁸ while hot brandy and water,³⁹ barley water,⁴⁰ and water-gruel and strawberries⁴¹ were also tried. The patient in the last of these cases was a student who survived for six weeks after being stabbed in the heart; his attending physician, a Dr Lavender, concluded that the strawberries had contributed to his demise.

The first indication that more positive surgical intervention was possible came in 1872, when a thirty-one-year-old pewterer became involved in a pub brawl in London. After the tussle he noticed that a needle he had been carrying in his coat had disappeared, and he wondered whether it had entered his chest. The following day he was in some pain, and went to St Bartholomew’s Hospital. The doctors could find no evidence of injury, so he went back to work; but nine days later he returned, still in pain and troubled by palpitations. He was examined by a surgeon called George Callender, who noticed a tiny bump between two of the ribs. He decided to investigate further, and after the patient had been given chloroform made a small incision into the pectoral muscle. To his surprise this revealed a small metallic object which vibrated with every heartbeat. With great delicacy he pulled at it with a pair of forceps, and a needle almost two inches long emerged from the man’s chest, having apparently been lodged inside the cardiac muscle. The patient made a good recovery, and when the details of the procedure were made public it quickly became the talk of medical London. It even earned the surgeon the rare distinction of becoming an eponym: ‘Callender’s operation’ was notable as the first occasion on which a patient had recovered after surgery to remove an object from the heart.⁴²

While a few early textbooks refer to Callender’s operation as the first heart surgery, he had not actually needed to expose the organ or make an incision into its surface. The first person to do this deliberately – albeit not on a human patient – was Dr Block, a surgeon from Danzig. At a meeting of the German Surgical Society in 1882 he began a presentation of his work by brandishing a rabbit’s heart. Some weeks earlier, he explained, he had cut open the animal’s ribcage and created an artificial wound in the surface of the organ. He had then repaired the damage with three stitches, and a few days later the rabbit had completely recovered. To make sure this outcome was not a one-off he repeated the experiment, on the same animal and others.⁴³

What particularly surprised Block was the organ’s resilience. In order to insert sutures into the rabbit’s heart he had to lift it out of the ribcage. He noticed that when he did this it stopped beating, and all breathing ceased. But as soon as it was released into its normal position all function resumed. Surgeons had long been terrified of touching the heart, fearing that even gentle manipulation might be enough to disturb its rhythm and cause instant death. But a much earlier writer, working in the seventeenth century, had already shown that it was quite a robust organ which would easily withstand careful handling.

The seventeenth-century English physician William Harvey contributed more than anybody to our understanding of what the heart is and what it does. He devoted years to his study of the movement of blood around the body, experimenting on an extraordinary range of creatures including dogs, rabbits, toads, lizards and crabs. Cold-blooded animals proved particularly useful, because they had a slow metabolism and therefore a slow heartbeat, allowing him to see more clearly what was going on. When Harvey began his work, most authorities still subscribed to Galen’s version of the action of the blood, a rather convoluted theory according to which arterial blood was manufactured in the heart and cooled by the lungs, while the liver produced the blood found in the veins. So great was Galen’s reputation in the seventeenth century that dissent from his views amounted to medical heresy; it says much for Harvey’s dedication to scientific truth that he was prepared to brave the consequences. His great discovery, laid out in his 1628 book De Motu Cordis (‘On the Movement of the Heart’), was that blood travelled around the body in a closed circuit, propelled by the heart.

For over a decade Harvey was physician to Charles I, who took an interest in his work, allowing him to conduct dissections on deer in the royal parks. In the 1640s Harvey met a young nobleman, the son of Viscount Montgomery, who had suffered a serious accident in childhood. This left him with a cavernous wound in his side which had failed to heal. When Harvey examined the opening, he found a large open space in the thorax, into which he could easily fit three of his fingers. Looking more closely, he noticed ‘a protuberant fleshy part’ which, he realised with astonishment, was the young man’s heart. He knew that his employer would be fascinated:

I carried the young man himself to the king, that his majesty might with his own eyes behold this wonderful case: that, in a man alive and well, he might, without detriment to the individual, observe the movement of the heart, and with his proper hand even touch the ventricles as they contracted.

Charles inserted the royal fingers into the gaping chasm in the youth’s flank and held the heart for himself, noting that this caused no pain or visible disturbance.⁴⁴ Here was clear evidence that the organ could be handled without danger; yet strangely this knowledge had already faded from view two centuries later.

Block was not the only researcher of the 1880s to suggest that it might eventually be feasible to stitch a human heart. An American surgeon, John Roberts, raised the possibility in 1881, although the main subject of his article was the pericardium, the fibrous sac that surrounds it. Sometimes when the heart is injured this natural envelope fills with blood, preventing the organ from beating effectively. This condition, known as cardiac tamponade, is potentially fatal, and at least two surgeons of the early nineteenth century are believed to have treated it by inserting a sharp probe to puncture the sac, allowing the blood to drain away. Roberts suggested that it might even be safe to open the pericardium to retrieve foreign objects, or to enable minor repairs of the heart muscle: ‘The time may possibly come when wounds of the heart itself will be treated by pericardial incision, to allow extraction of clots, and perhaps to suture the cardiac muscle.’⁴⁵

It was a decade before this prediction was proved correct. On 6 September 1891, a young man in St Louis, Missouri, was stabbed in a fight. He was taken to the city hospital, where his wound was dressed, but ten hours later his condition had deteriorated and he was taken into the operating theatre. No anaesthetic was used, presumably because time was of the essence – a decade later one prominent surgeon still thought anaesthesia ‘improper’ for such a procedure,⁴⁶ and it would not be routinely used for such major surgery until after the First World War.⁴⁷ When the dressings were removed, blood and air gushed from the wound. Henry Dalton, the surgeon in charge, opened the patient’s chest and turned him on his side in order to drain the blood. The incision revealed a two-inch wound in the pericardium which he managed to repair, after many attempts and with great difficulty: ‘I had no precedent to guide me, no authority to uphold me in attempting to sew up this wound over a heart that was beating at the rate of 140 per minute.’⁴⁸

At several points in the operation the patient appeared close to death, but on each occasion he was injected with a cocktail of strychnine and whiskey, which improved his condition. Strychnine is a highly toxic compound which was once used as rat poison, but at this date it was believed to be a useful stimulant which in small doses would elevate the heart rate. Whiskey also enjoyed something of a vogue in American operating theatres at the turn of the century: in 1900 John DaCosta recommended enemas of hot coffee and whiskey when treating heart injuries,⁴⁹ while the post-operative medication of a stab victim in Georgetown nine years later included three pints of whiskey administered in a single day.⁵⁰ European surgeons preferred Old World drinks: during an operation in the 1890s, Charles Ballance injected his patient with a mixture of brandy and saline, which had so dramatic an effect that by the end of the procedure, ‘he no longer seemed dead, but was so drunk and obstreperous that five men were required to hold him down’.⁵¹

Dalton’s patient made a rapid and uninterrupted recovery; an impressive success, but he had not interfered with the heart itself. That remained a threshold that few were willing to cross. From a modern perspective it can be difficult to understand what it was that deterred surgeons from taking the decisive final step, when they had already come so close. Writing a few years later, the American surgeon Charles Elsberg explained why he and his colleagues were so petrified of touching the beating heart:

We must remember that we have to deal with an organ of first importance which is in constant motion, and which, moreover, was believed to be very sensitive to the smallest mechanical insult or injury. It was feared that during the slightest manipulation the heart might suddenly stop, that the mere passage of a needle might be followed by the direst results.⁵²

What changed their minds? A flamboyant piece of theatre staged by the Italian researcher Simplicio Del Vecchio in 1894 may have been the catalyst. At a conference of surgeons in Rome he appeared on stage with a dog on a lead and proceeded to tell his colleagues that he had operated on this animal forty days earlier, puncturing its heart and repairing the wound by stitching. Two days later it was killed, and members of the audience were able to see for themselves that the wound had healed perfectly, leaving only a small scar. Del Vecchio was cautious about the prospects for human heart surgery, acknowledging that there were still important questions to be answered, such as whether it would be possible to administer an anaesthetic. But, he concluded, ‘I am confident that in the not too distant future surgery will answer all these questions, and that with the protection afforded by asepsis it will surmount still more serious obstacles.’⁵³

He did not have long to wait, for within a matter of months a surgeon in Norway had the courage not only to open the pericardium, but to attempt an operation on the structure of the heart itself – and even to insert a needle through its pulsating muscle. In the early hours of 4 September, a young man was rushed to the National Hospital in Oslo in a taxi, having been found at home lying in a pool of blood. He had been stabbed in the chest. When the thirty-seven-year-old duty surgeon, Axel Cappelen, examined him he found his unconscious patient ‘pale as a corpse’. The man briefly stopped breathing, and an hour later his pulse was barely detectable. Cappelen decided to operate. Once the patient had been put to sleep with chloroform and his chest opened, Cappelen found massive internal bleeding. There was a wound about three-quarters of an inch long in the left ventricle of the heart, which he sutured with catgut, timing each stitch to avoid the violent leaps of the organ as it contracted. This delicate job was eventually completed, and when the patient awoke the next day he said he felt much better. But his recovery was only temporary: he died on the morning of 7 September, having succumbed to blood loss from an undetected arterial wound.⁵⁴

⁵⁵Journal of the American Medical Association⁵⁶