Heart: A History
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About this ebook
The bestselling author of Intern and Doctored tells the story of the thing that makes us tick
For centuries, the human heart seemed beyond our understanding: an inscrutable shuddering mass that was somehow the driver of emotion and the seat of the soul. As the cardiologist and bestselling author Sandeep Jauhar shows in Heart: A History, it was only recently that we demolished age-old taboos and devised the transformative procedures that have changed the way we live.
Deftly alternating between key historical episodes and his own work, Jauhar tells the colorful and little-known story of the doctors who risked their careers and the patients who risked their lives to know and heal our most vital organ. He introduces us to Daniel Hale Williams, the African American doctor who performed the world’s first open heart surgery in Gilded Age Chicago. We meet C. Walton Lillehei, who connected a patient’s circulatory system to a healthy donor’s, paving the way for the heart-lung machine. And we encounter Wilson Greatbatch, who saved millions by inventing the pacemaker—by accident. Jauhar deftly braids these tales of discovery, hubris, and sorrow with moving accounts of his family’s history of heart ailments and the patients he’s treated over many years. He also confronts the limits of medical technology, arguing that future progress will depend more on how we choose to live than on the devices we invent. Affecting, engaging, and beautifully written, Heart: A History takes the full measure of the only organ that can move itself.
Sandeep Jauhar
Sandeep Jauhar is the bestselling author of several acclaimed books on medical topics: Intern, Doctored, and Heart: A History, which was named a best book of 2018 by The Mail on Sunday, Science Friday, and the Los Angeles Public Library, and was a PBS NewsHour/New York Times book club pick; it was also a finalist for the 2019 Wellcome Book Prize. A practicing physician, Jauhar writes regularly for the opinion section of The New York Times. His TED Talk on the emotional heart was one of the ten most-watched TED Talks of 2019.
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Reviews for Heart
38 ratings4 reviews
- Rating: 3 out of 5 stars3/5If there is one thing that you need more than your brain, then it is your heart. Over the course of a normal life, the heart will beat around 115,00 times a day which equates to 42 million times a year. Over your lifetime it will pump a staggering 158 million litres of blood. For years was seen as the centre of our soul too, but that attitude changed with the rise of scientific understanding of the way it worked. But what goes around comes around and modern research has shown how the heart can react and change shape as it reacts to feeling and trauma. It is the organ that is the very centre and essence of us.
Sandeep Jauhar has a close affinity with this organ, not only is he a practising cardiologist, but he only needs to go back to his grandparent's generation to find the roots of his own heart issues. That journey from them to him will take us to the pioneers and mavericks who have discovered so much about it. There is William Harvey who discovered that the blood flowed down the arteries and somehow passed through the flesh and was pumped back up the veins. Inge Edler who made the connection that ultrasound that was being used to find battleships could also be used on the heart to see it working and John Heysham Gibbon who spent thirty years of his life developing a heart and lung machine to oxygenate the blood, opening the doors to being able to perform surgery on the heart without the patient dying. This and many other innovations and groundbreaking advances have lead us to the point where we move ever closer to the artificial heart.
This is a good overview with enough depth in it too for the casual reader of how we have got to where we are now with our understanding and treatment of the heart. There is also Jauhar's personal story of heart disease in his own family and how it impacts his health, but how these diseases have affected all sorts of people from all levels of society. - Rating: 3 out of 5 stars3/5Fascinating history of the heart in culture and medicine. Dr. Jauhar personalizes the advances in cardiology and explains the limits of technology.
- Rating: 4 out of 5 stars4/5Sandeep Jauhar has been fascinated by the heart since he was a small boy. Lucky for him that he has been able to pursue a career as a highly trained cardiologist. And lucky for us that he is able to write. This book is a relatively small volume and the writing begins rather simply. As the book progresses he subtly introduces more complex, thought provoking ideas.History and culture imbue the human heart with a great deal of metaphoric and physical significance. To many it embodies the seat of emotion, the core of the soul, and it is the linchpin between life and death. Because of the heart's physical vulnerability, medical treatment was largely unexplored until the end of the 19th century. Dr. Jauhar chronicles the history of experimental and clinical cardiology with details of the (mostly) men who doggedly challenged physiological frontiers, sometimes to the point of their own demise.The central part of the book looks at the heart as a complex machine, with each chapter focusing on aspects of that machine: as a pump, a generator, wiring, etc. The writing is clear and accessible to a layperson. His goal is to foster understanding in the general public and he does that well. He takes us step wise through the development of the clinical understanding of those aspects of the heart and the treatments derived from that understanding.Woven through the narrative is the author's family history of heart disease and the impact those events on him and his family. Human emotion and the heart is a secondary theme throughout the book and he ends the book on that chord. After many years of clinical practice during rapid advances in surgical and pharmacological treatment of the heart, the author opines that we are at the point of diminishing returns in those areas. Perhaps the next great advances in the prevention and treatment of heart disease will come from our ability as a species to address the psychological, social, and political roots that lead to promoting the health and well being of our hearts.
- Rating: 4 out of 5 stars4/5Thanks to NetGalley for this ARC!
I am a big fan of the author and his writing, and HEART did not disappoint. There were many facts about the heart (some obscure, some not) interspersed throughout the book to complement patient stories. We read about the author as a young boy and his personal desire to work in cardiology, stemming from the story of a relative’s death during his formative years. The author comes across as a caring and knowledgeable doctor with a kind bedside manner – there are no veiled frustrations or jabs at ornery patients, as I have read in other medical books.
One of the best things about the book is that it’s part history, part medicine, part almost-gory-but-not-overly-done, and part philosophy. Each chapter can stand alone and be read a few days apart without having to remember the plot or which patient he is discussing. Thoughtful illustrations are added to underscore the meaning of the chapters, and footnotes are added to provide explanations or information without slowing down the flow of the narrative. The book strikes a great balance of science and interesting plot without slowing down the narrative with a lot of detail that the average reader without a medical background wouldn’t understand. For someone like me, with a medical background, there were also enough facts to keep me interested. Some books minimize details to make it easy for the reader; Jauhar does not do that. This makes his books fascinating and eminently readable.
Book preview
Heart - Sandeep Jauhar
Prologue: CT Scan
I’d been getting short of breath. When I walked up the scuffed steps to my fourth-floor office, I had to stop to rest. Sometimes, at night, I would start to wheeze as my airways congested with mucus, and I’d break into fits of cough. As a physician, I was privileged to have been a first responder on 9/11, but many of us who had been at Ground Zero were reporting respiratory problems. So I went to my friend Seth, a pulmonologist, for an evaluation. He ordered pulmonary function tests, in which I sat in a glass-walled booth and blew hard into a plastic tube. Airflow and lung volumes were normal. Seth diagnosed me with acid reflux, a common cause of chronic cough, and prescribed a daily antacid. But I persuaded him to order a CT scan of my chest. My symptoms seemed out of proportion to his benign diagnosis. I was worried that my lungs had been damaged by the smoke and dust I’d inhaled downtown.
As Seth predicted, the CT scan revealed normal lungs. However, an incidental finding caught my eye. Coronary artery calcifications are noted,
the report offhandedly stated. Coronary calcium is a marker of atherosclerosis, hardening of the arteries. It had been reported as an incidental finding on countless CT scans of my older patients over the years, and I’d scarcely paid any attention. But now, at age forty-five, I wanted to know more. How much calcium was present, and where, exactly? A radiologist informed me that the scan I’d had did not have the resolution to answer these questions.
On my computer, I pulled up a Framingham calculator, a tool designed to estimate one’s risk of a heart attack within the next ten years. I put in my height and weight, blood pressure and cholesterol, and the fact that I am a nonsmoker and don’t have diabetes. The program spit out a ten-year risk of a heart attack of 2 percent and of any cardiovascular event (including angina and stroke) of about 7 percent. Reassuringly low. However, I also knew that for an Indian immigrant with a strong family history of heart disease, the calculation probably underestimated the true risk.
My brother, Rajiv, also a cardiologist, suggested a treadmill stress test, but I was playing tennis on weekends without any symptoms. A stress test would only detect coronary blockages greater than 70 percent, and I was pretty sure my disease was not that advanced. So I opted for a special, noninvasive CT angiogram to look into my coronaries. Every Father’s Day I received spam e-mail about this test. Make sure Dad is not among the hundreds of thousands of men in America who appear healthy but are actually a ticking time bomb.
Strange to think that I might now be one of those men. I called Dr. Trost, the cardiac radiologist in our department, and scheduled the scan. She reassured me that I was at low risk for heart disease. But for your peace of mind, you should probably have it,
she said.
So, early one morning in June, I went for the test. While I lay on the gantry outside the C-shaped scanner, a tech inserted an IV in the back of my hand. The scan would have to resolve millimeter-sized plaque in a grapefruit-sized organ moving at a velocity of 200 millimeters per second. I was given an intravenous beta-blocker to slow down my heart to reduce image blur. A nitroglycerin tablet was also placed under my tongue to dilate my chest arteries so the scan could visualize them better. After a couple of preliminary images, a nurse injected X-ray-opaque dye into my vein. You’re going to feel warm all over,
she said as I blushed, thinking I had wet myself. The final run-through took less than a minute.
After Dr. Trost reviewed the images, she called me into the reading room. The gray-and-white pictures were up on a large monitor. White specks, radiographic grit, were in all three of my coronary vessels. The main artery feeding my heart had a 30 to 50 percent obstruction near the opening and a 50 percent blockage in the midportion. There was minor plaque in the other two arteries, too. Sitting numbly in that dark room, I felt as if I were getting a glimpse of how I was probably going to die.
Fear Heart (Courtesy of Darian Barr)
Introduction:
The Engine of Life
There is nothing shameful about a heart attack.
—Susan Sontag, Illness as Metaphor (1978)
Perhaps the most consequential event in my life occurred fifteen years before I was born. On a sweltering July day in India in 1953, my paternal grandfather died suddenly. He was only fifty-seven. The circumstances were unusual, and like most family tragedies, ours has acquired a touch of myth. Everyone agrees that in the morning on the day he died, my grandfather was bitten by a snake coiled between sacks of grain in his little shop in Kanpur. He did not see the type of serpent, but snakebite is common in India, and by all accounts my grandfather was feeling fine when he came home for lunch. My father, who was almost fourteen, was going for an interview at Kanpur Agricultural College the following day, and my grandfather had planned to accompany him. They were sitting on the stone floor, inspecting my father’s high school diploma, delighting in all the academic honors he’d received, when, midway through the meal, neighbors brought in the corpse of the shiny black cobra they claimed had bitten my grandfather. (It had been killed by a snake charmer summoned to the shop.) My grandfather took one look at it and went pale. How can I survive this?
he said, before slumping to the floor. The neighbors exhorted him to say Ram, Ram,
a Hindu prayer, but his last words, lying on the floor, his eyes turning to glass, were I wanted to take Prem to college.
A government ambulance used to make rounds in the village regularly. Around 7:00 p.m., several hours after my grandfather’s collapse, it was flagged down on a routine drive. By then, rigor mortis had set in, traveling like a slow wave from my grandfather’s neck and jaw into his limbs. The paramedics immediately declared my grandfather had passed—he had no heartbeat—but the family, in denial, insisted they take him (and the snake) to a British-built hospital about five miles away. A doctor there pronounced my grandfather dead on arrival.
It was a heart attack,
the doctor said, dispelling the family’s belief that a snake had killed their elder. My grandfather had succumbed to the most common cause of death throughout the world, sudden cardiac death after a myocardial infarction, or heart attack, perhaps triggered in his case by fright over the snakebite. With nothing to be done, and the summer heat threatening to spoil the body, my grandfather was brought back to the village and cremated the following day. Before a garlanded casket set on a pyre soaked in oil, people beat their heads in grief under a light blue sky.
Listening to family lore, I grew up with a fear of the heart as the executioner of men in the prime of their lives. Because of the heart, you could be healthy and still die; it seemed like such a cheat. The apprehension was fed by our grandmother, who came to live with us in California in the early 1980s (until she got homesick and returned to the tiny village in Kanpur where her beloved husband had died). Even thirty years after his death, she still wrapped herself in white gossamer shawls that smelled of mothballs, befitting a widow. Once, at the Los Angeles Zoo, she bowed respectfully to the snake they brought around, clasping her hands and muttering a prayer before insisting we take her home. She was a strong-willed woman who ably took over the reins of the household after her husband died. And yet, like Miss Havisham, she spent her life in mourning over one freakish, incomprehensible incident. In India, snakes symbolize infinity and timelessness, as well as misfortune and death. To the end, in her mind, it was a venomous snake that killed her husband. And in a way, in the suddenness with which a heart attack can fell a healthy and vibrant life without warning, it was.
My maternal grandfather also fell victim to sudden cardiac death, though many years later. He was an army doctor who set up a successful private practice at his home in New Delhi. On a September morning in 1997, just after his eighty-third birthday, he woke up complaining of abdominal pain, which he attributed to an excess of food and scotch the night before. After a few minutes, he bellowed a loud groan and went unconscious; just like that, he was gone. He almost certainly had had a massive heart attack, but that wasn’t what killed him. It was the ensuing arrhythmia—ventricular fibrillation, in which the heartbeat becomes chaotic—that prevented his heart from sustaining blood flow and life. When I talked to my mother about his death, she said she was sad that he died so suddenly. But she was thankful, too.
Thus, the human heart became an obsession for me, in no small part because of my family history. As a boy, I used to lie in bed and monitor the thudding in my own chest. I’d lie on my side, head in hand, and listen to the squirting pulse in my ears. I’d adjust the speed of the ceiling fan to synchronize with my heartbeat, in thrall to the two competing oscillators, so grateful that mine never took a rest.¹ I was fascinated by the heart’s dichotomous nature: muscular, constantly toiling, and yet so vulnerable at the same time. Years later, when I became a heart-failure specialist, I reproduced this preoccupation in my children. When my son, Mohan, was small, we used to watch a PBS special on heart disease, in which a man having a heart attack develops cardiac arrest. In the back of an ambulance, he is shocked back to life with defibrillator paddles, his body violently jerking with the electrical discharge. Mohan would stare at the scene spellbound, often rewinding the tape, until I’d insist we turn it off, fearful of the impact on his developing mind. We’d watch it again the next day.
* * *
This book is about what the heart is, how it has been handled by medicine, and how we can most wisely live with—as well as by—our hearts in the future. The heart’s vital importance to our self-understanding is no accident. If the heart is the last major organ to stop working, it is also the first to develop—starting to beat approximately three weeks into fetal life, even before there is blood to pump. From birth until death, it beats nearly three billion times. The amount of work it performs is mind-boggling. Each heartbeat generates enough force to circulate blood through approximately 100,000 miles of vessels. The amount of blood that passes through an average adult heart in a week could fill a backyard swimming pool. But the life that it sustains can quickly be taken away. When the heart stops, death is instantaneous. If life is a continuous struggle against the inexorable march of entropy, then the heartbeat is at the core of that conflict. By purveying energy to our cells, it counteracts our tendency toward dissipation and disarray.
More than anything, the heart wants to beat; this purpose is built into its very structure. Heart cells grown in a petri dish start to contract spontaneously, seeking out other cells (through electrical connections called gap junctions) to synchronize in their rhythmic dance. In this sense, cardiac cells—and the organ they create—are social entities. The heart can continue to beat for days, even weeks, after an animal has died. In a laboratory, the French Nobel laureate Alexis Carrel showed that properly nourished chick heart tissue cultured on a medium of blood plasma and water will pulsate for months and can remain alive for more than twenty years, much longer than the normal life span of its host. This is a unique property of the heart. The brain and other vital organs cannot function without a beating heart, but a beating heart does not depend on a functioning brain, at least not in the short term. Moreover, the heart doesn’t just pump blood to other organs; it pumps blood to itself. We cannot see our own eyes. We must struggle to use our minds to change our way of thinking. But the heart is different. In a sense, and unlike any other organ, the heart is self-sustaining.
Of all the connections of the heart—to emotions, to thought—the link between the heartbeat and life is perhaps the strongest. We associate the heart with life because, like life itself, the heart is dynamic. From second to second, and on a macroscopic scale, the heart is the only organ that discernibly moves. Through its murmurings, it speaks to us; through its synchronized contractions, it broadcasts an electrical signal several thousand times more powerful than any other in the body. Over the centuries, disparate cultures have viewed the heart as the source of a life-giving force that was to be culled or harvested. In ancient Egypt, the heart was the only organ that was left in the body during mummification because it was believed to play a central role in the rebirth of an individual after death.² In a scene often depicted in Egyptian mythology, the heart of a deceased person is weighed on a scale balanced by a feather or statuette representing truth and divine law. If the heart balanced evenly, it was considered pure and returned to its owner. But if it proved laden with sin, it was devoured by a monstrous chimera, and the deceased was banished to the underworld. Three thousand years later, in elaborate hilltop ceremonies, the Aztecs opened the chests of slaves with flint knives and ripped out their still-beating hearts as offerings to their idols. In Western fairy tales, witches seeking immortality consumed the hearts of innocents. In Snow White, for example, the evil queen insists the hunter cut out the girl’s heart to ensure that she is really dead. Even today, when brain death has become a widely accepted sign of demise, people continue to associate a heartbeat with viability. Families come up to me in the intensive care unit and say, His heart is beating. How could he be dead?
The sanguine dance must eventually come to an end. Cardiovascular disease claims 18 million lives—nearly one-third of all deaths—across the globe each year. Since 1910, heart disease has been the number one killer in the United States. Today 62 million Americans (and more than 400 million worldwide, including 7 million in the United Kingdom) suffer from heart disease.
The second most common cause of death in America is cancer, but heart disease and cancer could hardly be more different. In cancer, cells divide madly, migrate wildly, invade mercilessly, in a sort of hard-charging pollution of the body. Heart disease is different: cleaner, stricter, less ambiguous, more comprehensible. Cancer patients, Susan Sontag wrote, are stained and fragmented. Cardiac patients, she said, often stand tall, seemingly healthy, like my grandfather, until they die.
The numbers could be even worse. Cardiovascular deaths in America have actually declined by almost 60 percent since the mid-1960s. From 1970 to 2000, the average life span in the United States increased by six years. Two-thirds of this increase in longevity came from advances in cardiovascular treatments. (In recent years there has been decreasing life span in middle-aged whites for non-cardiovascular reasons.) Although more than 60 percent of Americans will develop some form of cardiovascular disease in their lifetime, less than a third will die of it, so we know our treatments are effective. The twentieth century will go down in history as one in which the great scourge of cardiovascular disease finally began to come under control.
There is a downside to this success, of course. Patients who once might have died of heart disease now must live with it, though often in an enervated state, a fraction of their former selves. Every year more than half a million Americans develop congestive heart failure, in which the heart weakens or stiffens to the point that it cannot properly pump blood to meet the energy demands of the body. Heart failure is now the number one reason patients over sixty-five years old are hospitalized, and most patients still die within five years of diagnosis. Ironically, as we become more adept at treating heart disease, the set of people who are ill with it is growing.
The cardiovascular situation in America is likely going to get worse in the coming years. Adherence to a heart-healthy lifestyle has decreased. In aggregate, Americans have become more obese and sedentary, and smoking rates have hardly changed in the past two decades. An autopsy study in the Archives of Internal Medicine suggests that 80 percent of Americans sixteen to sixty-four years old have at least the beginnings of coronary artery disease. These findings indicate that the four-decade-long decline in heart disease may be coming to a screeching halt. We will need new ways to cope with this threat.
In the pages that follow, I will examine the emotional and scientific dimensions of an organ that has intrigued and eluded philosophers and physicians for centuries. No other organ—perhaps no other object in human life—is so imbued with metaphor and meaning. The history I will describe is not one of uninterrupted progress, but it is one that, in fits and starts, has solved major challenges, helping countless people survive a disease that was once considered terminal. It is a grand story—from the natural philosophers who dwelled on the heart’s metaphorical meanings, to William Harvey and the discovery of circulation, to large-scale endeavors like the Framingham Heart Study that explored the causes of heart disease, to modern surgical techniques and technologies that even a century ago, because of the heart’s exalted status in human culture, were considered taboo.
The twelfth-century Christian mystic Hildegard of Bingen once wrote, The soul sits at the center of the heart, as though in a house.
In many ways, the heart does resemble a house. It is divided into multiple chambers, separated by doors. The walls have a characteristic texture. The house is old, designed over many millennia. Hidden from view are the wires and pipes that keep it functioning. And though the house has no intrinsic meaning, it carries meaning because of the meanings we attribute to it. The heart was once considered the center of human action and thought—the source of courage, desire, ambition, and love. Even if those connotations are outdated, they are still deeply relevant to how we think about this organ and how it shapes our lives.
PART I
Metaphor
Separation, Edvard Munch, 1896, oil on canvas, 96.5 × 127 cm (Munch Museum, Oslo [MM M 00024]; photograph © Munch Museum)
1
A Small Heart
You can die of a broken heart—it’s scientific fact—and my heart has been breaking since that very first day we met. I can feel it now, aching deep behind my rib cage the way it does every time we’re together, beating a desperate rhythm: Love me. Love me. Love me.
—Abby McDonald, Getting Over Garrett Delaney (2012)
When I was fifteen, I had to do a research project for my high school biology class. I decided to measure the electrical signal from the heart of a live frog. To do the experiment, I was going to have to pith the animal—sever its spinal cord while it was still alive, thus paralyzing it—before cutting it open. I borrowed an oscilloscope to measure current, a voltage amplifier, and some red and black electrodes. My science teacher, Mr. Crandall, said it was an impressive project for a high school junior.
But first I had to collect some frogs. With a fishing net in one hand and my bicycle handlebars in the other, I set off for the woods near my house in Southern California. It was a late Friday afternoon in early spring, and birds were singing petulantly. The road was wet. My bicycle tires made gritty sounds in the gravelly mud.
My destination was a small pond, no bigger than a backyard swimming pool. The surface was blanketed with leaves, dragonflies, and interconnecting swaths of green muck. I plodded along the bank, my sneakers sinking ever so slightly into the mud. Then, through a parting in the algae, I beheld a wondrous world of darting tadpoles and surging tree frogs. I plunged my net, a white mesh at the end of a three-foot wooden pole, into the water and dragged it along the viscous bottom. When I pulled it out, a small yellow frog was caught in the netting. I dropped it (along with a few leaves) into a garbage bag. With a few more sweeps, I collected more frogs, about six in all. I poked tiny holes in the plastic bag with the tip of a pencil and tied off the top. Then, after stuffing the bag into my backpack, I rode home.
I dropped the bike at the side of the house and unlatched the wooden door leading to the backyard. Weeds peeked out of cracks in the cement path. Beside the covered patio was a small lemon tree. The fact that it was there always made me feel as if my backyard were a better, freer place than it really was. By then, darkness was approaching, replacing the jaundiced sky. From the kitchen, my mother called out to me to come in for dinner. I left the bag with the frogs on the patio. Inside, my mother asked me if I was going to feed the animals. I told her there was no point because they were going to be sacrificed