Author: Sandeep Jauhar
This book is about an organ which the author said is ‘imbued with metaphor and meaning‘, and which has ‘intrigued and eluded philosophers and physicians for centuries’. It is as much an examination of the mechanical and electrical functions of a critical organ, as it is an exploration of the rich medical and cultural history of the heart. The author, a cardiologist, also chronicled the technological innovations that have defined his specialty and advanced it to a stage where he feared that it ‘might have reached the limits of what it can do to prolong life‘. But beyond a professional and historical narrative, the book is also a portrayal of the diverse pathologies that afflict the heart, and impact on the physical and emotional health of an increasing number of people. The contents of the book are particularly poignant because the author’s heart itself has a compromised arterial blood supply; this, along with an unsettling family history of early cardiac death, explains why the heart is an ‘obsession‘ for him. His professional and personal pedigree therefore made him well-placed to depict both the grandeur of the heart and the misery that attends its failure (pages 5-13 and 238-239).
Of the many functional perspectives of the heart which the author conveyed, the one that stood out was the traditional one of the heart as an ‘electrical organ‘ – a role that begins in the third week of foetal life ‘even before there is blood to pump’. The author depicted a complex symphony of heart cells synchronising their contractions, and continuing to beat even when an animal has died. The author however noted that the spontaneous pacemaker activity of the heart, generated by the sinoatrial node, also constitutes a vulnerability which may manifest as self-sustaining and potentially fatal arrhythmias which may be set off relatively innocuously by common triggers such as trauma. Emphasising the gravity of these abnormal rhythms which include ventricular fibrillation, the author argued that they in effect make the heart a metaphorical ‘grim reaper‘. The author was nevertheless concerned that the model of the heart as a ‘biomechanical pump‘ has enabled the overuse of mechanical interventions such as pacemakers, a situation he felt ignores the fact that the heart is also ‘the physiological canvas upon which our emotions are most easily written’ (pages 10, 150-158 and 130).
In an account that showed how closely the heart and the emotions interact, the book explored the role of the organ as the seat of sentiments and affections. With a narrative infused with metaphor, and designed to show that the heart is more than just a machine, the author reviewed how the physical functioning of the organ is affected by such factors as ‘emotional stresses, worries, and fears‘. Citing research evidence which demonstrate that ‘heartbreak can cause heart attack‘, the author highlighted the relationship of emotional states to heart activity using the example of Takotsubo cardiomyopathy, what the author referred to as the broken-heart syndrome. This, he explained, is a condition that makes the heart appear ballooned on echocardiogram – reminiscent of a Japanese octopus trapping pot which has ‘a round bottom and a narrow neck‘. Because this cardiomyopathy is the consequence of the literal flooding of the heart by the stress hormone adrenaline, the author referred to it as ‘the archetype of a disease that is controlled by interactions between the emotions and the physical body‘. He elaborated on the potential causes of Takotsubo cardiomyopathy , pointing out that it may be triggered as much by major catastrophes such as earthquakes, as by such relatively trivial experiences as ‘public speaking and domestic disputes‘ (pages 21-31).
Amongst the most compelling themes of the book is how our understanding of the heart has evolved, and how this has enabled life-saving cardiac interventions to emerge. In this regard, the author noted such breakthroughs as the observation by the Persian anatomist Ibn al-Nafis that the pulse reflects the ‘force of cardiac contractions‘; the deduction by Andreas Vesalius that ‘to get to the left side of the heart, blood must pass through the lungs‘; and the discovery by William Harvey that ‘blood circulates continuously in a circuit from the arteries to veins and back again’. Equally compelling were the accounts of pioneering cardiac surgical operations such as the first drainage of a traumatic pericardial effusion by the black surgeon Daniel Hale Williams; the ventricular septal defect closure operations under cross-circulation by C. Walton Lillehei; the first coronary artery bypass operation by Michael Rohman; and the first cardiac transplantation by Christiaan Barnard. The book also recounted the intrigue and controversy that accompanied the so far unsuccessful attempts to develop a permanent artificial heart, noting the early efforts of rivals Denton Cooley and Michael DeBakey, and the later endeavours of William DeVries and Robert Jarvik (pages 40-45, 61-97, 186-188, 73, 90-96 and 190-195).
At the heart of the book are the technological innovations that enabled cardiologists to better investigate and treat the diseases that afflict the arteries of the heart. One such seminal breakthrough the author commemorated was cardiac catheterization, a technique he referred to as ‘undoubtedly one of the greatest medical discoveries of the twentieth century’. The narrative described how Werner Forssman first carried out this procedure on himself in Germany in 1929 – a bold self-experimentation which at first earned him the censure of his institution, but eventually earned him the Nobel Prize in 1956 along with Andre Counard and Dickinson Richards. In a similar way, the author referred to the ‘brazenness‘ of Mason Sones who used coronary angiography to demonstrate the location of arterial plaques; he pointed out that Sones fortuitously developed the idea after the tip of his cardiac catheter accidentally ‘slipped into the opening of the right coronary artery‘. Another significant development was the introduction of balloon coronary angioplasty by Andreas Gruentzig; the author referred to this technique, itself adapted by a method developed by Charles Dotter, as the innovation that ‘ushered in the field of interventional cardiology‘ (pages 102-111 and 134-143).
A heartbreaking theme of the book relates to the harrowing epidemiology of heart disease which has become ‘the number one killer in the United States’. To support this contention, the author referred to the influential Framingham Heart Study, running since in 1948, as the study that exposed the extent of heart diseases in the community; the was the study, for example, that identified cigarette smoking, hypertension, and diabetes as important risk factors for coronary heart disease. The author nevertheless stressed that the Framingham study ‘does not tell the whole story‘ because it did not take into account such factors as the effect of migration, urbanisation, socioeconomic class, and emotional states. Beyond the epidemiology of heart disease, the book also explored the clinical impact of coronary artery disease, remarking that ‘the source of most of mankind’s misery is the fatty plaque‘ which, by obstructing the flow of arterial blood, is ‘responsible for heart attacks and strokes, the most common ways we die’. Aside from coronary artery disease, the book also explored other heart diseases such as cardiac tamponade, a situation which develops when ‘rapid collection of pericardial fluid or blood can quickly put the heart into standstill’, and which makes the heart appear on echocardiogram like ‘a small animal confined to a tiny pool…struggling to get free’ (pages 13, 118-133 and 56-60).
This is an informative and enlightening review of the physiology and pathophysiology of a crucial bodily organ. The book graphically portrayed the history of the innovations and interventions that have enabled heart specialists to investigate and treat the whole spectrum of heart disorders. The author draws attention to the factors that threaten the heart, from the conventional cardiac risk factors such as smoking, to the peculiar such as emotional stress; in this way he provides a more holistic outlook to an organ which symbolises life itself. The contents are further enhanced by the depictions of the pioneers who have transformed the investigation and treatment of cardiac diseases. Whilst the author’s personal anecdotes were informative, the stories occasionally seemed to distract from, rather than complement, the otherwise flowing and gripping scientific narrative. Whilst the range of cardiac disorders the book tackled was relatively narrow, dominated by coronary heart disease, it nonetheless explored these exhaustively.
The heart is an important organ and this book demonstrates how its elaborate functions may become impaired. The author’s professional expertise as a cardiologist, and his personal experience of heart disease, were evident throughout the book. He highlighted the cutting-edge technological interventions that may remedy cardiac disease, but he emphasised the more important but prosaic public health approaches to their prevention. The contents of the book are relevant to healthcare and I recommend it to all doctors.
Publisher, Place, Year: One World Books, London, 2018
Number of chapters: 14
Number of pages: 269
Star rating: 4