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Suturing of Penetrating Wounds to the Heart in the Nineteenth Century: The Beginnings of Heart Surgery

2011; Elsevier BV; Volume: 92; Issue: 5 Linguagem: Inglês

10.1016/j.athoracsur.2011.07.056

1552-6259

Vladimir Alexi‐Meskishvili, Wolfgang Böttcher,

Medical History and Innovations

The beginnings of cardiac surgery go back to the 19th century. This article describes the history of the first attempts to operate on the heart. In 1882, Dr Block from Danzig, and in 1895, Simplicio Del Vecchio, published reports of animal experiments showing that the suturing of heart wounds is possible. After unsuccessful attempts by Axel Cappelen in Norway and Guido Farina in Italy, it was Ludwig Rehn of Germany who first sutured a laceration of the right ventricle of a human heart. Shortly afterward, Antonio Parrozzani successfully sutured a stab wound of the left ventricle. Following cardiac surgery back to its very beginnings, it is striking that the first attempts in the 19th century to repair the injured heart were regarded with great skepticism, and that heart suturing only slowly became an established method of treatment. Once the concept of cardiac surgery had become accepted, however, many kinds of operations were developed, paving the way for an explosion in the number of cardiac operations, as we well know, in the century that followed. The beginnings of cardiac surgery go back to the 19th century. This article describes the history of the first attempts to operate on the heart. In 1882, Dr Block from Danzig, and in 1895, Simplicio Del Vecchio, published reports of animal experiments showing that the suturing of heart wounds is possible. After unsuccessful attempts by Axel Cappelen in Norway and Guido Farina in Italy, it was Ludwig Rehn of Germany who first sutured a laceration of the right ventricle of a human heart. Shortly afterward, Antonio Parrozzani successfully sutured a stab wound of the left ventricle. Following cardiac surgery back to its very beginnings, it is striking that the first attempts in the 19th century to repair the injured heart were regarded with great skepticism, and that heart suturing only slowly became an established method of treatment. Once the concept of cardiac surgery had become accepted, however, many kinds of operations were developed, paving the way for an explosion in the number of cardiac operations, as we well know, in the century that followed. "The glory of a surgeon is like that of an actor: they live only so long as they are alive, and their talent leaves no trace when they are gone. Actors and surgeons, like great singers too, like the executants who by their performance increase the power of music tenfold, are all the heroes of a moment."—Honoré de Balzac, "The Atheist's Mass," 1837 In 1868, Georg Fischer from Hannover, Germany collected 452 cases of heart wounds from all sources available at that time and found a healing rate of only 15.9%. At that time, these injuries were treated conservatively using rest, external wound bandages, and blood-letting, universal treatment methods of that time [1Fischer G. Die Wunden des Herzens und des Herzbeutels.Archiv für Klinische Chirurgie. 1868; 9: 37-910Google Scholar]. The first cardiac surgical procedures were operations in which, after thoracic incision, the pericardium was opened to drain accumulations of fluid [1Fischer G. Die Wunden des Herzens und des Herzbeutels.Archiv für Klinische Chirurgie. 1868; 9: 37-910Google Scholar, 2Aris A. Francisco Romero, the first heart surgeon.Ann Thorac Surg. 1997; 64: 870-871Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 3Shumacker H.B. When did cardiac surgery begin?.J Cardiovasc Surg (Torino). 1989; 30: 246-249PubMed Google Scholar]. In early 1801, Francisco Romero from Barcelona successfully performed such an operation. In his work published in 1815, Romero [4Romero F. [Observatio experimentis confirmata, pro hydrope pectoris, pulmonum anasarca, et hydropericardio cognoscendis; et nova methodus dictos morbos operandi.]. Veuve Jansonius, Paris1815Google Scholar] described his method of open pericardial drainage and reported several successful operations. Romero is considered by some authors to be the first heart surgeon [2Aris A. Francisco Romero, the first heart surgeon.Ann Thorac Surg. 1997; 64: 870-871Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 3Shumacker H.B. When did cardiac surgery begin?.J Cardiovasc Surg (Torino). 1989; 30: 246-249PubMed Google Scholar, 5Van Thielen J. Nan Hee R. Pericardiotomy: the first cardiac operation.Acta Chirurg Belg. 2008; 108: 133-138PubMed Google Scholar]. The second such operation is thought to be the attempt by Baron Dominique Jean Larrey (1766–1842), the surgeon-in-chief of the Napoleonic armies, to save the life of the 30-year-old infantryman Bernhard Saint-Ogne who had stabbed himself in the chest on March 18, 1810 in a suicide attempt. The patient survived only 21 days after the procedure. Another patient, a 22-year-old soldier, was operated on 14 years later on February 23, 1824, and survived the operation. Larrey performed experiments on corpses and described a technique for pericardiotomy [5Van Thielen J. Nan Hee R. Pericardiotomy: the first cardiac operation.Acta Chirurg Belg. 2008; 108: 133-138PubMed Google Scholar]. That suturing heart wounds was feasible was predicted by John Bingham Roberts (1852–1924). Presenting a paper before the Anatomical and Surgical Society of Brooklyn in 1881, he noted [6Roberts J.B. Heart-puncture and heart suture as therapeutic procedure.Transactions & Studies of the College of Physicians of Philadelphia. 1881; 6: 215-219Google Scholar]: "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." In the following year, at the 11th Congress of the German Society of Surgery in Berlin, Block from Danzig described how he had undertaken experiments on rabbit hearts, whereby he had "healed an artificially caused wound by suturing." He showed for the first time that suturing of heart wounds would lead to similar healing as in any other sutured wounds [7Block M. Über wunden des Herzens und ihre Heilung durch die Naht unter Blutleere.Verh Dtsch Ges Chir. 1882; 2: 108-110Google Scholar]. In Italy in 1895, Simplicio Del Vecchio also proved that experimental heart suturing in dogs was possible [8Del Vecchio S. Sutura del cuore.Riforma Medica. 1895; 11 (50-3): 38-40Google Scholar]. Charles Albert Elsberg (1871–1948) of New York reported, in 1899, animal experiments to surgically treat extensive cardiac wounds and concluded [9Elsberg C.A. An experimental investigation of treatment of wounds of the heart by means of suture of the heart muscle.J Exper Med. 1899; 4: 479-520Crossref PubMed Scopus (8) Google Scholar]: "Above all my experiments seem to show that a mammalian heart will bear a much greater amount of manipulation than has hitherto been suspected. Very large wounds of the heart can heal and the healing process occurs in a manner entirely analogous to that in other muscular tissues." Elsberg [9Elsberg C.A. An experimental investigation of treatment of wounds of the heart by means of suture of the heart muscle.J Exper Med. 1899; 4: 479-520Crossref PubMed Scopus (8) Google Scholar] was probably the first to draw attention, in 1898, to a supposed quotation from Theodor Billroth, namely, that "Many years ago Billroth declared the opinion that no surgeon who wished to retain the respect of his colleagues would ever attempt to suture a cardiac wound." Despite well-founded doubt [10Absolon K. Theodor Billroth and cardiac surgery.J Thorac Cardiovasc Surg. 1983; 86: 451-452PubMed Google Scholar], this supposed citation is still appearing in some modern publications [11Kapadia S. Topol E. Cardiac trauma.in: Topol E.J. Textbook of cardiovascular medicine. Lippincott Williams & Wilkins, Philadelphia2007: 698-709Google Scholar, 12Soreide K. Soreide J. Axel H. Cappelen, MD (1858–1919): first suture of a myocardial laceration from a cardiac stab wound.J Trauma. 2006; 60: 653-654Crossref PubMed Scopus (9) Google Scholar]. Rudolf Haecker [13Haecker R. Experimentelle Studien zur Pathologie und Chirurgie des Herzens.Archiv für Klinische Chirurgie. 1907; 84: 1035-1098Google Scholar] also mentioned Billroth's alleged deprecatory view of heart surgery in 1907: "Despite the progress made as a result of the introduction of antiseptics Billroth rejected the suggestion made by Roberts in 1881 of suturing the heart muscle injured by stabbing, declaring that the surgeon who tried such a procedure could lose the respect of his colleagues." Possibly, these reports of Billroth's alleged position originate in a section of his Handbook of General and Special Surgery, which states [14Billroth T. [Krankheiten der Brust.in: von Pitha F. Billroth T. Handbuch der allgemeinen und speciellen Chirurgie: mit Einschluss der topographischen Anatomie, Operations- und Verbandlehre; Bd 3 Specielle topographische Chirurgie, Operations- und Verbandlehre: Abth 2, A, Abschn 6.]. Enke, Stuttgart, Germany1882: 63-164Google Scholar]: "The paracentesis of the hydropic pericardium is, in my opinion, an operation approaching rather closely that point which some surgeons call prostitution of the art of surgery, others a surgical frivolity. Only to avoid the accusation of external incompleteness in this chapter do we mention this operation for which the anatomists generally show more interest than clinicians. Maybe further generations may think differently; internal medicine is becoming more and more surgical and the physicians primarily engaged in internal medicine tend to make the boldest operative plans." However, in view of the fact that Billroth himself performed a puncture of the pericardial cavity in 1881, it seems unlikely that he would have been against heart suturing in the same period [15Schober K.L. The quotation about the heart Comments on Theodor Billroth's attitude toward cardiac surgery.Thorac Cardiovasc Surg. 1981; 29: 131-137Crossref PubMed Scopus (5) Google Scholar]. Professor Karl Ludwig Schober [15Schober K.L. The quotation about the heart Comments on Theodor Billroth's attitude toward cardiac surgery.Thorac Cardiovasc Surg. 1981; 29: 131-137Crossref PubMed Scopus (5) Google Scholar] of Halle, at that time in East Germany, extensively researched the source of Billroth's comments on cardiac surgery and concluded that "Billroth has neither written nor spoken the quotation about the heart. On the other hand I am almost sorry that I cannot defend him now against thoughtless assaults which have been and will be made on him because of his alleged quotation." Nevertheless, this discussion seems to demonstrate a generally doubtful attitude to heart surgery at its very beginning. In 1888, Riedinger [16Riedinger F. [Verletzungen und chirurgische Krankheiten des Thorax und seines Inhalts.in: Billroth T. Lücke A. Deutsche Chirurgie.]. Enke, Stuttgart, Germany1888Google Scholar] wrote: "The idea of suturing a heart wound, although made in all seriousness, scarcely deserves to be mentioned." Even after the successful animal experiments demonstrating the feasibility of heart suturing performed by Block and Del Vecchio, Stephen Paget [17Paget S. Surgery of the Chest. Wright, Bristol1896Google Scholar] writes in his work Surgery of the Chest, published in 1896, that "no new method, and no new discovery, can overcome the natural difficulties that attend a wound of the heart." The Norwegian Axel Hermansen Cappelen (1858–1919) (Fig 1) dared to perform the first heart suture in a human on September 4, 1895, at the Rikshospitalet in Kristiania, today's Oslo. He attempted to treat a 24-year-old man with a stab wound to the left ventricle measuring about 2 cm [18Cappelen A. Vulnus cordis, suture of hjertet.Norsk Magasin för Laegevidenskaben. 1896; 6: 285-288Google Scholar] (Fig 2). The patient had sustained a knife wound below the fourth left rib. Owing to the massive loss of blood, Cappelen decided to operate immediately. Having performed left lateral thoracotomy, he resected parts of the third and fourth rib. That enabled him to rule out a lung injury as a result of the stabbing. The existing pericardial wound was enlarged, and injury to a coronary artery became visible; this was sutured with cat-gut sutures.Fig 2Title page of an article containing the first report of a heart suture by Axel Hermansen Cappelen [18Cappelen A. Vulnus cordis, suture of hjertet.Norsk Magasin för Laegevidenskaben. 1896; 6: 285-288Google Scholar].View Large Image Figure ViewerDownload (PPT) On the first postoperative day, the patient could already eat again. However, after a fever developed, he died on the morning of September 7. The autopsy showed mediastinitis to have been the cause. It was also established that the ventricular wall had not been entirely penetrated, and that an injury to the coronary artery was the source of the bleeding. Unfortunately, Cappelen omitted to specify in his publication the year in which the operation was performed. and later authors give different dates. Baksaas and Solberg [19Baksaas S.T. Solberg S. Verdens vørste hjerteoperasion.Tidsskrift for den Norske Lægeforening. 2003; 123: 202-204PubMed Google Scholar], authors from the Rikshospitalet in Oslo, date the operation to September 4, 1895. The second surgeon to perform heart suturing was Guido Farina (1868–1939). He treated a 7-mm stab wound of the left ventricle in Rome [20Farina G. Situra del ventricolo dextre.Bull Acad Med Roma. 1896; 23: 248Google Scholar]. This operation was mentioned only briefly in a contribution by Franceso Durantes to a discussion at the 11th Congress of the Italian Society for Surgery in 1896, which was published in the Zentralblatt der Chirurgie [21Salomoni A. [Diskussion zu: Kleinere Mitteilungen. 14) XI. Kongress der Italienischen chirurgischen Gesellschaft, gehalten in Rom vom 26–29 Oktober 1896, Beitrag zur Chirurgie des Herzens.].Centralblatt für Chirurgie. 1896; 23: 1224Google Scholar]. It was not until 1910 that John Bland-Sutton was able to report this case in detail [22Bland-Sutton J. A clinical lecture of the heart.Br Med J. 1910; 1: 1273-1276Crossref PubMed Scopus (3) Google Scholar]. Bland-Sutton described heart suturing in one of his own cases and mentioned in this regard the content of a letter he had received from Farina in December 1909. Farina reported that he had sutured a heart wound in March 1896 in the Spedala della Consolazione. A 30-year-old man suffered a stab wound made by a thin, sharp knife in the fifth intercostal space. This left a 7-mm wound in the right ventricle. Farina resected part of the fifth rib from the sternum to reach the heart. He closed the cardiac wound with three silk sutures and placed two further stitches between them. The wound healed without complications, but severe bronchial pneumonia developed, and the patient died 3 days later. The autopsy showed a perfectly healed wound. Farina asked the legal authorities to let him have the heart for further examinations, but this was refused. He described his irritation about this as the reason why he did not wish to report this interesting case in detail at the time. The first successful cardiac surgical procedure is generally regarded as being the suturing of a stab wound to the right ventricle performed by Ludwig Rehn (1840–1930) (Fig 3) on September 9, 1896, in Frankfurt am Main, Germany [23Rehn L. Ueber penetrirende Herzwunden und Herznaht.Archiv für klinische Chirurgie. 1897; 55: 315-329Google Scholar] (Fig 4).Fig 4Title page of the first report of successful heart suture performed by Ludwig Rehn [23Rehn L. Ueber penetrirende Herzwunden und Herznaht.Archiv für klinische Chirurgie. 1897; 55: 315-329Google Scholar] (from the authors' collection).View Large Image Figure ViewerDownload (PPT) His patient, the 22-year-old gardener William Justus, had received a knife wound to the chest in the night of September 7, 1896. Rehn first saw the patient on September 9 on his return from a journey. He had the impression that the patient was dying and diagnosed rapidly increasing hemothorax. Rehn's colleague Siegel had already established by means of a probe that the wound canal led in the direction of the heart. Rehn decided to attempt hemostasis without knowing which anatomic structures were actually injured. Following a 14-cm incision in the fourth left intercostal space and dividing of the fifth rib, a small stab wound to the pericardium was discovered, from which dark blood was continuously flowing. After the pericardium had been further incised in a diagonal direction, a wound measuring approximately 1.5 cm in the middle of the right ventricle could be seen in diastole. Rehn described the operation: "I quickly decided to suture the heart wound. A fine intestinal needle with a silk suture was used. At the beginning of the diastole the needle was introduced at the left side of the wound, quickly and deeply. It seemed as if the diastole was thereby lengthened. In the following diastole the suture was knotted. Again the heart seemed to remain in diastole a moment longer. It was encouraging that the bleeding was considerably weaker after the first ligature had been knotted. Using the first suture to fix the injured area the placement of the second button suture was greatly alleviated. It was only frightening that the heart seemed to remain still in diastole at each fixation. After placement of the third suture, which was particularly difficult because of the movement of the heart, the bleeding completely stopped. The heart continued to beat and we were able to breathe a sigh of relief. The assistant reported that the patient's pulse was much better." The patient recovered and remained well. The second successful operation of its kind, which also represents the first suturing of an injury to the left ventricle, was performed by Antonio Parrozzani (1870–1930) at the Hospital Santa Maria della Consolatione in Rome, Italy [24Parrozzani A. I primi due casi di sutura del ventriculo sinistro.Bulletino della Reale Accademia Medica Di Roma. 1897; 22: 243-260Google Scholar] (Fig 5). The 32-year-old laborer Adolfo Barboni had been stabbed with a dagger in the seventh left intercostal space on the night of April 18 to 19, 1897. Because the patient was in extremely poor condition 5 hours after the attack owing to extreme loss of blood, the decision to operate was taken. The operation was done by integrating the wound into the outer incision. The 2.5-cm pericardial wound was enlarged to approximately 6 cm. A 2-cm long wound in the heart apex became visible, with blood spurting from it with every heartbeat. Parrozzani put the little finger of his right hand into the hole, stopping the bleeding, and was able to fixate the apex at the same time. Using a large, curved needle he pierced the whole of the myocardium, without touching the endocardium, and knotted the suture, at the same time removing his finger from the wound. Although each prick of the needle further excited the heart and removing the finger obscured the view through the sudden flow of blood, the surgeon was able to completely stop the bleeding by placing three additional sutures. After 75 minutes, the operation was ended successfully [24Parrozzani A. I primi due casi di sutura del ventriculo sinistro.Bulletino della Reale Accademia Medica Di Roma. 1897; 22: 243-260Google Scholar]. The authors of several reviews of this period tried to count the numbers of heart sutures performed before the turn of the century, but arrive at different figures because some cases were counted double and some cases in which no heart wound suturing was performed were also included in the statistics [25Djanelidze Y.Y. Cardiac injuries and their surgical treatment [in Russian]. Leningrad Med J Co, Leningrad1927Google Scholar]. In a report written in 1899, Loison [26Loison E. Des blessures du péricarde et du coeur et de leur traitement.Revue de Chirurgie. 1899; 19: 49-73Google Scholar] counted 21 cases of surgical treatment of heart wounds until then. Of these patients, 13 died and 8 recovered (38% were successful). The surgical procedures with lethal outcome were probably not necessarily published. Also, the statistics of injuries with favorable outcome without operation included needle injuries, of which approximately 40% could be healed without an operation. The surgically treated cases were those with severe stab or shot wounds. Of the 22 reports of heart suturing that we found during our analysis of all original articles about heart wounds published in the 19th century, 11 concerned wounds to the left ventricle and 9 to the right ventricle. In one instance, the coronary artery branch and left ventricle had been injured, and in 1 case, the left atrium (Table 1). It was not possible to find out the exact date of operations in all cases. Of the 22 patients operated upon, 8 survived. The other 14 died, some of them only a few hours postoperatively because of massive bleeding and anemia or several days later because of pleural and mediastinal infection [27Vaugan G. Suture of the wounds of the heart.JAMA. 1909; 52: 429-438Crossref Scopus (4) Google Scholar].Table 1Suturing of Penetrating Wounds to the Heart Reported in the Nineteenth CenturyAuthorDate of Operation or ReportInjured Area of the HeartResult of Operation1. CappelenSeptember 4, 1895LV/coronary arteryDied after few days2. FarinaMarch 1896RVDied on 7th day3. RehnSeptember 9, 1896RVSurvived4. ParrozzaniApril 19, 1897LVSurvived5. ParrozzaniJune 3, 1898LVDied on 2nd day6. FummiApril 23, 1898Heart apex/LVSurvived7. NinniBefore August 14, 1898LVDied on table8. ParlavecchioReported in August 1898LVSurvived9. GiordanoJuly 6, 1898Left atriumDied on 19th day10. NeumannFebruary 2, 1898RVDied after 45 minutes11. PagenstecherJuly 12, 1898LVSurvived12. Tuzzi1898LVDied on 22nd day13. LongoSeptember 4, 1898LVDied after 10 minutes14. MarionNovember 11, 1898RVDied on table15. HorodynskiDecember 6, 1898RVDied on 22nd day16. BufnoirReported on January 20, 1899RVDied17. NicolaiReport of 1899RVDied after 12 hours18. MaliszewskiMarch 3, 1899LVDied on 4th day19. MaliszewskiApril 4, 1899LVDied after 26 hours20. RosaSeptember 10, 1899LVSurvived21. RamoniSeptember 22, 1899RVSurvived22. LisantiReport of 1899RVSurvivedIn six cases (nos. 2, 8, 12, 16, 17, and 22) only the year of the operation is indicated in the original articles. All original publications from the 19th century are available in PDF format for scientific use from the authors on request.LV = left ventricle; RV = right ventricle. Open table in a new tab In six cases (nos. 2, 8, 12, 16, 17, and 22) only the year of the operation is indicated in the original articles. All original publications from the 19th century are available in PDF format for scientific use from the authors on request. LV = left ventricle; RV = right ventricle. Suturing of the left ventricle was survived by 5 of 11 patients, and 3 of 9 patients survived suturing of the right ventricle (Table 1). The first suture of the injured left atrium was reported by the Italian surgeon E. Giordano [28Giordano E. Il primo caso di sutura del seno sinistro del cuore.La Riforma Medica. 1898; 3: 674-693Google Scholar] in 1897 and of the right atrium by another Italian surgeon, G. Ninni [29Ninni G. Un'altra sutura del cuore per ampia ferita penetrante del seno destro.La Riforma Medica. 1901; 205: 650-656Google Scholar], in 1901. Both cases were unsuccessful. Not until the beginning of the 20th century were cases of successful suturing of atrial injuries reported by Schwerin [30Schwerin Operative Behandlung der einer Stichverletzung des rechten Herzvorhofes mit Krankenvorstellung Verhandl der Deutsch Gesel f Chir 32 Congress. 1903; 32: 166-168Google Scholar] (right atrium), and by Kappeler [31Kappeler O. Stichschnittwunde des linken Vorhofs, Herznaht Heilung.Langenbecks Arch Chir. 1904; 72: 603-612Google Scholar] (left atrium). On October 27, 1913, Yustin Djanelidze [32Alexi-Meskishvili V. Konstantinov I. Yustin Y. Djanelidze and the first successful repair of an injured ascending aorta.Tex Heart Inst J. 2000; 27: 113-116PubMed Google Scholar, 33Djanelidze Y. A case of the repair of an injury of the ascending aorta [in Russian].Khir Arkhiv Veniaminova. 1916; 1: 87-102Google Scholar] performed the first successful repair of a penetrating injury of the ascending aorta. Median sternotomy as a surgical approach to the heart was described only in 1897 by the British surgeon Herbert Meyrik Nelson Milton (1856–1921) [34Milton H. Mediastinal surgery.Lancet. 1897; : 872-875Abstract Scopus (63) Google Scholar], and it was not used for suturing of heart wounds in the 19th century. The approach to the heart in practically all cases reported before 1900 was made by means of some type of osteoplastic or chondroplastic flap, including a varying number of ribs from the third to the seventh [25Djanelidze Y.Y. Cardiac injuries and their surgical treatment [in Russian]. Leningrad Med J Co, Leningrad1927Google Scholar, 35Ware M. Surgery of the heart.Ann Surg. 1899; 30: 518-529Crossref PubMed Google Scholar]. Use of ether anesthesia is reported in some cases [36Pagenstecher Durch die Naht geheilte Wunde des linken Ventrikels, ein Beitrag zur Herzchirurgie.Deutsche Medizinische Wochenschrift. 1899; 25: 523-526Crossref Scopus (2) Google Scholar], but operations were also performed without any anesthesia [37Horodynski W. Maliszewski W. O ranach serca. Przyczynek do operacyjnego leczenia zranien serza wraz z opisem trzech wlasnych spostrzezen.Medycyna. 1899; 27: 469-544Google Scholar]. Catgut [18Cappelen A. Vulnus cordis, suture of hjertet.Norsk Magasin för Laegevidenskaben. 1896; 6: 285-288Google Scholar], silk [20Farina G. Situra del ventricolo dextre.Bull Acad Med Roma. 1896; 23: 248Google Scholar, 22Bland-Sutton J. A clinical lecture of the heart.Br Med J. 1910; 1: 1273-1276Crossref PubMed Scopus (3) Google Scholar], or celluloid [36Pagenstecher Durch die Naht geheilte Wunde des linken Ventrikels, ein Beitrag zur Herzchirurgie.Deutsche Medizinische Wochenschrift. 1899; 25: 523-526Crossref Scopus (2) Google Scholar] was used as a suturing material. In reports from the 19th century, there is no mention of the lighting or the instruments used during operations on the injured heart, but one can presume that conditions were far from ideal. Rehn [23Rehn L. Ueber penetrirende Herzwunden und Herznaht.Archiv für klinische Chirurgie. 1897; 55: 315-329Google Scholar] himself concluded his description of the first successful heart suture as follows: "The feasibility of heart suturing should surely no longer be doubted. I also do not need to fear objections questioning the need for the suture, since the procedure was not only directly life-saving but also seemed fortunately to avoid the late consequences of pericardial adhesions. I hope and am confident that this case will not remain just a curiosity but that it will provide the stimulus to further develop the area of heart surgery. I reiterate my conviction that heart suturing can save many a life that so far had to be considered lost." Having described a case of successful heart suturing that he performed, Pagenstecher [36Pagenstecher Durch die Naht geheilte Wunde des linken Ventrikels, ein Beitrag zur Herzchirurgie.Deutsche Medizinische Wochenschrift. 1899; 25: 523-526Crossref Scopus (2) Google Scholar] wrote in 1899: "I am far from wanting to make the varied heart operations into typical procedures to be practiced by any physician, although our efforts so far have shown very good results. I freely admit that the position of the surgeon in view of the patient who is bleeding to death and on the brink of the grave is not a pleasant one and carries the most severe responsibility." A little later, Rudolf Haecker [13Haecker R. Experimentelle Studien zur Pathologie und Chirurgie des Herzens.Archiv für Klinische Chirurgie. 1907; 84: 1035-1098Google Scholar] wrote: "Surgery of the heart is an achievement of the past decade. Since ancient times the heart has been regarded as 'noli me tangere' and with it the last organ of the human body has now fallen to the hand of the surgeon." The next step in the history of heart surgery was predicted by Samways [38Samways D.W. Cardiac peristalsis: its nature and effects.Lancet. 1898; 1: 927Abstract Scopus (29) Google Scholar] in an article in the April 2, 1898, issue of The Lancet, in which he conjectured that, with progress in surgery of the heart, some of the most serious cases of mitral valve stenosis might also be treated by an operation. The legacy of the great surgeons of the past is their pioneering attempts to explore new means of treatment for incurable diseases in their time. Following cardiac surgery back to its very beginnings, it is striking that the first attempts in the 19th century to repair the injured heart were regarded with skepticism and that heart suturing only slowly became an established method of treatment. Once the concept of cardiac surgery had become accepted, however, many kinds of operation were developed, paving the way for an explosion in the number of cardiac operations, as we well know, in the century that followed. We thank Anne Gale, medical editor, for assistance with this article. We also appreciate the assistance of Astrid Benhennour, Professor Dominique Metres, and Professor Pascal R. Vouhé, who provided us with copies of all the original articles, and Carla Paolini, MD, who translated original Italian publications.