Did Daniel Hale Williams really perform the first successful heart surgery?

On July 9, 1893, operating on a patient who was stabbed in the heart, Dr. Daniel Hale Williams sewed up a tear in the pericardium (the sac surrounding the heart muscle) but left the heart muscle itself alone, allowing a small nick there — about one tenth of an inch in length — to heal on its own (Williams, 1897). Published histories of cardiac surgery attach little importance to this event, when they mention it at all. The lay media, however, often refer to it as the first successful heart surgery — a claim that is now as popularly accepted as it is false.

There is some question of whether operations on the pericardium, involving no incisions or stitches in the heart proper, even qualify as heart surgery. If not, then the first successful operation on the human heart did not truly take place until 1896 when Ludwig Rehn of Germany repaired a stab wound to the right ventricle. Stephen Johnson, in his book History of Cardiac Surgery (1970), expresses a common opinion when he writes that Rehn's accomplishment "marked the beginning of cardiac surgery; for the first time a surgeon had successfully operated on a living human heart."

But even if we count the pericardium as part of the heart, Dr. Williams' claim to distinction is spoiled by other surgeons who operated on the pericardium before he did. One of these was the now-forgotten Henry C. Dalton of St. Louis, who performed a procedure which according to Lillehei (1987) was "almost identical" to that done by Williams. Dalton reported his feat in Annals of Surgery about two years before Williams published a similar report in Medical Record. Likewise, the date of operation recorded in Dalton's article precedes by almost two years the date recorded by Williams. Johnson (1970) affirms the priority of Dalton:

On September 6, 1891, H.C. Dalton, a professor of surgery in St. Louis, performed the first suture of the pericardium during an operation on a twenty-two-year-old man who had been stabbed in the chest. Two years later, Daniel H. Williams, a skilled Negro surgeon from Chicago, also sutured the pericardium during an operation on a twenty-four-year-old victim of a stab wound in the heart. Both patients recovered.

Harris Shumacker in Evolution of Cardiac Surgery (1992) agrees:

As far as is known, the first repair of a pericardial wound was performed at the City Hospital in St. Louis on September 6, 1891, by Henry Dalton, professor of abdominal and clinical surgery at the Marion Sims College of Medicine. ... A second procedure was performed at the Provident Hospital in Chicago on July 10, 1893 by Daniel Hale Williams, although it was not reported until March 1897.

Another type of pericardial surgery goes even further back. In the early 19th century, Francisco Romero of Spain incised the pericardium to drain fluid compressing the heart, with the patients recovering in two of three cases. Baron Dominique-Jean Larrey, Napoleon's chief surgeon, is credited with a similar operation in 1810 on a patient whose pericardial cavity filled with blood following a stab wound to the heart. That patient survived for less than a month, but another drainage carried out by Larrey in 1824 led to a better outcome (Westaby, 1997). Shumacker (1989) comments:

Heart surgery is generally regarded as having begun on September 10, 1896 when Ludwig Rehn sutured a myocardial laceration successfully. There are valid reasons, however, to believe that cardiac surgery had its origin nearly a century earlier with the operative drainage of the pericardium by the little known Spanish surgeon, Francisco Romero, and highly regarded Baron Dominique Jean Larrey. This procedure entailed making a thoracic incision and opening and draining the pericardium. ... When Romero first operated is unknown, but it antedated 1814 when his work was presented in Paris; Larrey's operation was performed in 1810.

Aris (1997) claims to have settled the question of who was first, on the basis of memoirs presented by Romero in 1815 to the Society of Medicine in Paris:

Francisco Romero, a Catalonian physician, became the first heart surgeon when he performed an open pericardiostomy to treat a pericardial effusion in 1801. [...]

The first patient, a 35-year-old farmer named Antonio de Mira, was operated on in the spring of the first year of the century (meaning 1801). Five pounds of brick-colored fluid were drained. He made a good recovery, going back to work in 4 months. Three years after the operation his only complaint was pain in the incision.

As should be obvious by now, who gets credit as the first successful heart surgeon depends on a number of subjective criteria for what constitutes "true" heart surgery. There is, however, no reasonable combination of technicalities that would award primacy to Daniel Hale Williams, who operated only on the pericardium and was not even the first to do so.

These rare and relatively simple cardiac procedures of the 19th century should not be confused with modern open heart surgery using cardiopulmonary bypass. The modern procedure, which allows cutting the heart open to operate on its interior, required a method of diverting the blood flow away from the heart and lungs and was not achieved until the 1950s. Among its most important pioneers were C. Walton Lillehei, whose extensive contributions to the field earned him the nickname "father of open heart surgery"; and John Gibbon, principal inventor of the heart-lung machine.

References/Bibliography

Absolon KB, Naficy MA (2002). First successful cardiac operation in a human, 1896: a documentation: the life, the times, and the work of Ludwig Rehn (1849-1930). Rockville, MD : Kabel, 2002

Aris A (1997). Francisco Romero, the first heart surgeon. Annals of Thoracic Surgery. 64(3):870-1

Dalton HC (1895). Report of a case of stab wound of the pericardium, terminating in recovery after resection of a rib and suture of the pericardium. Annals of Surgery 21:147

Hessel EA (2001). Cardiac anesthesia timeline. ASA Newsletter 65(10).

Johnson SL (1970). History of Cardiac Surgery, 1896-1955. Baltimore: Johns Hopkins Press.

Lillehei CW (1987). Commentary on Daniel Hale Williams. In: Organs CH, Kosiba MM, eds. A Century of Black Surgeons : the U.S.A. experience. Norman Oklahoma:Transcripts Press. 332-334.

Meade RH (1961). A History of Thoracic Surgery. C.C. Thomas, Springfield, IL

Richardson RG (1969). Surgeon's Heart: a History of Cardiac Surgery. London: Heinemann Medical

Shumacker HB Jr. (1989). When did cardiac surgery begin? Journal of Cardiovascular Surgery (Torino). 30(2):246-9.

Shumacker HB Jr. (1992). Evolution of Cardiac Surgery. Bloomington, IN: Indiana University Press

Wertenbaker LT (1980). To Mend the Heart. New York: Viking Press

Westaby S, Bosher C (1997). Landmarks in Cardiac Surgery. Oxford: Isis Medical Media

Williams DH (1897). Stab wound of the heart and pericardium - suture of the pericardium - recovery - patient alive three years afterward. Medical Record 51:439.