The Matter of the Heart

The Matter of the Heart
Author: Thomas Morris

Synopsis

This enlightening book is a historical excursion into how the forbidding barriers that once protected the heart were breached by the pioneers of heart surgery. It narrates the stories of what the author calls the ‘fearless’ and ‘powerful characters’ who ventured to operate on the congenital and acquired cardiac disorders that were hitherto death sentences. With flowing narrative, the author brought alive the gruelling experiments and disappointing failures that culminated in really breathtaking accomplishments. The book is a thrilling mosaic of domineering personalities and egoistic rivalries, and a literal heart-stopping montage of trail-blazing operations. Along with fascinating facts about the heart, and the technologies that enabled its defects to be fixed, the book is an invaluable chronicle of some of humanity’s greatest achievements.

The first heart operation in Moldova (1972) CC BY-SA 2.0, Link

In his whirlwind depiction of the earliest history of heart surgery, the book traced the original imaginative attempts to operate on a live, beating heart. It is interesting that even after the introduction of anaesthesia and antisepsis, the heart remained an inaccessible organ, the reverence with which it was held discouraging many from braving to operate on it. The first person the book documented who successfully operated on the human heart was Ludwig Rehn, the surgeon who repaired a stab wound in the heart muscle and thereby achieving ‘lasting fame and the adulation of his colleagues’. Subsequent notable earlier achievements lauded in the book included those of Werner von Mantruffel, the first person to remove a foreign body – a bullet – from inside the heart, and of Dwight Harken, ‘one of the most highly regarded surgeons in the US Medical corps’, who extracted shell fragments from beating hearts in what the author described as surgery of ‘sophistication and audacity‘ (pages 2-3, 6-7 and 18-20).

CC BY-SA 4.0, Link

Perhaps the most dramatic heart operation the book described, and which compellingly captured the public imagination, was the first ever heart transplant operation. As the author provided a detailed account of the innovative research and competitive race that led to the breakthrough, he also painted a vivid picture of the colourful personality of the South African surgeon Christiaan Barnard, the first person to achieve the feat in 1967. The author depicted Barnard as ‘a naturally gifted surgeon’ with ‘unshakeable perfectionism‘ but with a ‘belligerent behaviour towards his staff’. The book provided a detailed description of the seminal surgery that established Barnard’s fame, and the media frenzy and celebrity status that followed. It also highlighted the controversies that surrounded Barnard, contending for example that he ‘was not even the first surgeon to give a patient a new heart’. Rather, the author stressed the extensive background research, carried out by different scientists, which enabled Barnard’s achievement; these include the works of Vladimir Demikhov, Peter Medawar, Joseph Murray, James Hardy, and especially Alexis Carell, ‘the most thorough of these early transplantation researchers’. The book also lauded the achievements of Barnard’s competitors in the heart transplant race such as Norman Shumway, Richard Lower, and Adrian Kantrowitz (pages 214-240 and 221-228).

Washkansky recovers after the transplant. Mallix on Flickr. https://www.flickr.com/photos/mallix/3611519554

A key insight the book provides is the scale of collaborative work that facilitated the success of the early heart operations. This is perhaps best illustrated by the author’s depiction of the innovative operation developed to treat tetralogy of Fallot, a debilitating congenital heart disease which is composed of ventricular septal defect, a narrow pulmonary artery, an aorta that communicated with both ventricles, and a thickened right ventricle. The author recounted how the ingenious idea for the surgery to correct this condition which manifests as ‘blue babies‘ was conceived by the paediatric cardiologist Helen Taussig, and how the operation was performed by Alfred Blalock whose assistant, Vivien Thomas, had perfected the procedure in animals. Indeed the author portrayed Thomas as Blalock’s ‘talented surgical technician with a sophisticated grasp of anatomy and physiology’. The coordinated approach to the surgery, the Blalock-Taussig-Thomas shunt, was evident in the author’s portrayal of the momentous events that transpired both inside and outside the operating theatre. The book’s account of other heart surgeries, such as the closure of the patent ductus arteriosus pioneered by Robert Grosse, also portrayed this type of productive collaboration (pages 26-40 and 45-49).

Tetralogy CC BY-SA 3.0, Link

The history of heart surgery is not complete without a review of the discord that tore two leading but opposing pioneering surgeons apart. In exploring this gripping theme, the author recounted what the intense cardiac surgical rivalry between Michael DeBakey and Denton Cooley, his protégé at Texas Medical Center. Describing them as ‘two of the greatest surgeons of the twentieth century’, the author recalled that they collaborated for ten years until they fell out. This was initially about priority over the successful repair of fusiform aortic aneurysms, but the rivalry that ‘began as a clash of egos‘ escalated into ‘a case of mutual antagonism‘ during the race to develop the first artificial heart, a situation that made their relationship turn ‘distinctly chilly‘. The author noted that whilst Cooley ended upoutshining his master’, the subsequent ethical and legal fallouts eventually tarnished his reputation because the device he inserted was developed by DeBakey. It was however gratifying that Cooley and DeBakey ended their ‘bitter and protracted‘ saga when they reconciled after forty years (page 70-71, 264-268 and 281).

Original prototype of Liotta-Cooley artificial heart. Karon Flage on Flickr. https://www.flickr.com/photos/karonf/8491319240

The scope of cardiac surgical inventiveness depicted in the book is staggeringly bewildering, the author chronicling countless outstanding innovations. Two which stood out for their critical roles in the whole cardiac surgical enterprise were the invention of the heart-lung machine by John Gibbon, and the discovery, by Jay McLean, of heparin – the anticoagulant that enabled Gibbon’s heart bypass machine to work successfully. Of the interventional cardiac innovations, the book particularly stressed the impact of cardiac catheterization – pioneered by Werner Forssmann who lost his job for the daring self-experiment; coronary angiography – introduced by Gunnar Jonsson; transluminal angioplasty – devised by Charles Dotter; percutaneous transluminal balloon coronary angioplasty – established by Andreas Gruntzig; and the first permanent artificial heart – invented by Robert Jarvik and inserted by William DeVries. The author also reviewed implantable defibrillators, coronary artery bypass grafting, coronary endarterectomy, heart valve repair, and cardiac pacemakers – ‘the most common medical device in the world’. Other cutting-edge and emerging techniques covered in the book included bioprostheses, robot-assisted procedures, membrane oxygenation, and cardioplegia (pages 88-117, 271-297, 121-184, 192-213).

CC BY-SA 2.0, Link

Opinion

This is an exhilarating history of the developments and personalities that made striking breakthroughs in the surgical treatment of heart disease. With detailed portraits of the pioneers and their characters, and perhaps with overly technical descriptions of the operations they devised, the book covers the subject comprehensively. The author’s meticulous descriptions of the underlying disorders are exceptionally educational and greatly enhanced the chronological narrative. The book’s portrayal of the rivalries that permeated the history of cardiac surgery is perhaps a reflection of the personalities that were attracted to the specialty by its high risk nature, as well as of the human appeal of primacy in such a high-profile field.

Overall assessment

This book has highlighted the major disorders of the heart which are amenable to surgery, and in the process it has emphasised the hard work and persistence that are essential in making medical breakthroughs. The heart is central to medicine and health, and it is connected to, and influences the function of, every other organ in the body. The book illustrates this in its coverage of prominent surgically-amendable disorders, and in its lessons on the technical and human dimensions of health care, and I recommend it to all doctors.

Book details

Publisher, Place, Year:  Vintage Books, London, 2017
Number of chapters: 11
Number of pages: 414
ISBN: 978-1-784-70325-7
Star rating: 4
Price: £9.01

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