The heart has always had a central role in human imagination and iconography. Most languages are littered with references to the heart as the seat of the soul and emotion. This is not entirely surprising – we all have found that when we are anxious or excited, we become aware of our heart pounding away. I remember how my entire rib cage would sometimes reverberate when carrying out particularly dangerous operations in my first months as a consultant neurosurgeon, when my patients’ lives had suddenly become my sole responsibility.
William Harvey elucidated the circulation of the blood in the 17th century, with animal experiments that are almost unbearable to modern sensibilities, but it was another 200 years before scientific medicine, with its increasingly mechanistic explanations of human physiology, really took off. One of the remarkable aspects of the history of medicine is how slowly it advanced – if at all – before the modern era. Paracelsus, for instance, was anaesthetising chickens with ether in the 16th century but it was another 300 years before it rapidly entered medical practice. Antonie van Leeuwenhoek’s invention of the microscope in the 17th century was not used in medicine until 200 years later.
With the rise of scientific medicine, the heart came to be seen as a pump and the idea that people could die “from a broken heart”, or any other of the conceits of romantic literature, was dismissed as little better than a folk story. Heart disease was a consequence of physical changes in the blood supply to the heart, to its electrical conduction system or its valves. In recent decades, however, it has been re-established that there is, after all, much truth in the idea that the heart and emotions are closely connected, and that states of mind can have a profound effect on our cardiac health.
The heart is intimately connected to the brain – in technical terms by the nerves of the sympathetic and parasympathetic systems, as well as by circulating hormones, the release of which is under cerebral control. In states of stress the sympathetic system is active, and the heart beats furiously; in states of relaxation the parasympathetic system is active and the heart slows down (only in orgasm are both systems simultaneously active). In diseases such as Takotsubo cardiomyopathy, the heart takes on the shape of an eponymous Japanese fishing pot in response to severe stress. The disease mimics a heart attack and was discovered in people who have survived catastrophes such as earthquakes or floods. In some cases it can even prove fatal. In one study of 117 patients who had survived acute cardiac arrhythmias, one in five had suffered public humiliation, bereavement or a similarly stressful event within 24 hours before their attacks. Four in five had not, which only confirms that almost all diseases are multifactorial, a concept with which our human brains and the Daily Mail, always keen to reduce complex phenomena to single causes, struggle.
All this, and much more, is beautifully described in Heart: A History, by the American cardiologist Sandeep Jauhar. He recounts the history of cardiology – a history of experimentation on animals, patients and sometimes by doctors on themselves. In the 1920s Werner Forssman, for instance, revolutionised cardiology by inserting a catheter through a vein in his arm into his own heart – something deemed impossibly dangerous until then. It is a story of dramatic technological progress and yet Jauhar concludes that: “We have moved away from the emotional heart to a narrow focus on the biomechanical pump”, and this, he tells us, has hurt patients. He would agree with Shakespeare, who observed in Love’s Labour Lost that “A light heart lives long”.
Jauhar joins a distinguished group of Asian-American doctors, such as Atul Gawande, Siddhartha Mukherjee and the late Paul Kalanithi, who are all gifted authors, writing for the general public. It is probably of some relevance that medicine in America is a postgraduate degree – in marked contrast to Europe. Put bluntly, American doctors are better educated than their European counterparts.
As has become almost obligatory in contemporary medical writing, Jauhar weaves his own personal and family story into his history of the heart. He does this very effectively. Indeed, his book starts by describing his own CT angiogram, and the evidence of early coronary artery disease, which runs strongly in his family. “I felt as if I were getting a glimpse of how I was probably going to die,” he says, on looking at the images of his own heart. This gives a certain dramatic tension to the book, as it tells the fascinating and rather wonderful history of cardiology, concluding with his acceptance of his own cardiac disease and mortality, but with a decision to take a little more exercise and perhaps strive a little less hard in his work.
The book is indebted – as Jauhar is at pains to point out – to The Lost Art of Healing, published in 1996, by the great American cardiologist Bernard Lown, who invented the direct current or DC cardiac defibrillator, and received the Nobel Peace Prize on behalf of International Physicians for the Prevention of Nuclear War. A true scientist, he was also deeply interested in what might be called the psychosomatic aspects of cardiac function. Lown tells many stories of his patients who seemed to be dying from heart failure but were revived by being given hope. Lown (who is still alive) openly admits to lying to patients as a therapeutic strategy. Hope, he argues – as all doctors know if they care to think about it – is a very powerful drug.
In the modern era, Lown writes, doctors are too frightened both of being accused of paternalism and of being wrong. They are also increasingly driven by expensive technology and investigations, and in many countries by profit-seeking. This is all at the expense of listening to patients and treating them not as diseased bodies but as fellow human beings in need of hope and psychological support, as well as diagnosis and physical treatments. This is not to say that being polite and kind to patients, and trying to give them hope, will cure cancer or enable us to live forever, but there is irrefutable evidence that states of mind have a powerful influence on cardiac function and probably, but less certainly, on immune function as well. Our state of mind, of course, is greatly influenced by our physical as well as our social environment. As Florence Nightingale observed in her Notes on Nursing, published in 1859: “Little as we know about the way in which we are affected by form, by colour, and light, we do know this, that they have an actual physical effect…” The division of mind from matter, sanctified by Descartes, was always a mistake.
Nine Pints by Rose George is a series of essays loosely connected to the subject of blood. She has previously written, the back cover tells us, about human waste and deep-sea shipping, among other subjects. Her research – which at times reads rather like a slightly breathless documentary voiceover – takes her all over the world.
She goes to a remote corner of Nepal to talk to women in a culture where menstruation is seen as unclean and where women must be secluded in separate huts when menstruating. She relates this to continuing taboos in the modern world about menstruation. (Apparently, Gordon Brown felt unable to tell parliament, when presenting the Budget in 2000, that he had generously reduced VAT on tampons to 5 per cent.) She goes to Canada to explore the fact that plasma (what is left when the red and white blood cells are removed from whole blood) can be collected on a commercial basis, whereas blood donation is voluntary in most countries.
There have been many deaths from HIV and hepatitis C from plasma given to haemophiliacs, and medical authorities were often egregiously slow to react to the fact that the plasma came from people at the bottom of the social ladder in America, who often harboured these diseases and had sold their blood.
There is an interesting chapter on the history of the Blood Transfusion Service in this country and the key roles played by the obscure civil servant Percy Oliver and the less obscure Janet Vaughan. George makes much of the tremendous prejudice Vaughan had to overcome as a woman in a mainly male medical profession. It is indeed, looking back, extraordinary how readily women’s intellects were dismissed in the past (and still are in many parts of the world) but the book does tend in places to the wisdom and outrage of retrospect. Pliny the Elder, for instance, is sternly criticised for being “wrong… wrong in abundance” about menstruation.
George also travels to South Africa to explore the impact of HIV and how for many years the government refused to allow the use of antiretroviral drugs. She goes to the London Hospital to learn about the role of huge blood transfusion and aggressive surgery in severe trauma cases (a subject recently dealt with in detail in Emily Mayhew’s excellent book A Heavy Reckoning).
Jauhar’s and George’s books present a marked contrast in style. Jauhar tells us that “the human heart became an obsession with me” and his book, about the heart, comes from the heart. It is a subject in which he is entirely expert, and is written with great eloquence. Rose George’s book is a work of detailed journalism, covering what are essentially disparate and sometimes very complex subjects.
In the past, the heart and blood were seen as being in some way central to human existence. In reality, they are no more important than any of the other major organs – we cannot live without a liver or kidneys (other than on dialysis), or a brain or the skin, or the lungs. We are an incredibly complex community of cells and organs and bacteria. Indeed the microbiome – as the trillions of bugs in our guts are called – are increasingly being implicated in health and diseases, such as Parkinson’s. But some organs, perhaps, have more poetic appeal than others.
Henry Marsh is a consultant neurosurgeon. His books include “Admissions: A Life in Brain Surgery” (Weidenfeld & Nicolson)
Heart: A History
Sandeep Jauhar
Oneworld, 288pp, £14.99
Nine Pints: A Journey Through the Mysterious, Miraculous World of Blood
Rose George
Portobello, 384pp, £14.99
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This article appears in the 28 Nov 2018 issue of the New Statesman, How the Brexit fantasy died