Heart: A History

by Sandeep Jauhar

with a balding scalp, a Punjabi beak nose, and wrinkled leathery cheeks.

Callused hands generally suggest blue-collar work. My cadaver’s hands were smooth and polished.

The left lung, for example, has only two lobes, unlike its tri-lobed counterpart on the other side. (The left lung’s middle lobe atrophies during fetal development because the heart gobbles up its space.)

A few snips and we released the heart from its beige scaffolding. A lab mate placed it on the cadaver’s forearm. “This guy really wears his heart on his sleeve,” he said.

Plato also proposed that the heart was a sentry—the thymos, the highest part of the mortal soul—through which blood rushes to warn that something is amiss.

Galen’s theories were accepted as the final word on cardiovascular—indeed all human—anatomy in the West. Through the Middle Ages, his writings were scripture, immune to questioning. People focused on his conclusions, not the (often scant) observations upon which his conclusions were based.

A more advanced understanding of the heart probably existed in Persia, where the physician Ibn al-Nafis wrote his Commentary on Anatomy in 1242. Ibn al-Nafis was born in Syria and received his medical education in Damascus, before moving to Cairo.

Among hundreds of Leonardo’s anatomical illustrations, a great many are devoted to the cardiovascular system. His earliest studies were on pigs and oxen, but he also dissected human cadavers—about thirty in all, from infants to centenarians—that he collected from hospitals in Florence and Rome. Leonardo,

University of Padua to study medicine. Although Harvey discovered the mechanism of circulation in 1615, he waited thirteen years before publishing his results. He feared for his safety; challenging Galenic dogma was considered sacrilegious. He might have been worried that he’d suffer the same fate as Michael Servetus, a theologian who was burned at the stake in Geneva at the age of forty-two, in part for promoting the idea that blood passes through the lungs.

Harvey never understood the purpose of circulation. He figured out the how of circulation but not the why.

Unlike neurologists, master diagnosticians who had depressingly little to offer their patients, cardiologists had been at the forefront of technological innovation over the past half century.

The dazzling technological complexity of the field was reflected in the apprehension most doctors had in managing heart disease. The same doctor who felt comfortable treating diabetes, kidney failure, or anemia would consult a cardiologist for even a mildly abnormal electrocardiogram (EKG). The heart can kill quickly, without warning, faster than any organ,

Inge Edler, a cardiologist, and Carl Hellmuth Hertz, a physicist, invented echocardiography at the University of Lund in Sweden in the early 1950s. They went to shipyards to study sonar, making the conceptual leap that if you can use ultrasound to see a ship five hundred meters away, maybe you can use it to see the heart, too, if only you could change the depth of penetration.

Therefore, as late as the early nineteenth century, the prescribed treatment for cardiac wounds leading to fluid accumulation and tamponade was absolute quiet and the application of leeches. Not surprising, then, that more than 90 percent of patients died.* But despite this awful mortality rate,

Once the heart is stopped to cut it open, a timer starts to tick. Deprived of oxygen-rich blood from the heart, the brain and vital organs will get irreversibly damaged within three to five minutes. However, most congenital heart malformations require at least ten minutes of circulatory stoppage to repair, too long to avoid brain injury.

Lillehei inserted plastic catheters into Gregory, while his assistants inserted separate catheters into Lyman. The boy was then connected to his father, vein to vein, artery to artery, via a beer hose passing through a Sigmamotor milk pump.

More than 600,000 Americans were dying of heart disease every year. In 1945, the budget for medical research at the National Institutes of Health was $180,000. Five years later, it was $46 million.

Toward the end of his first year at Jefferson Medical College in Philadelphia, John Heysham Gibbon Jr. considered quitting medicine to become a writer, a passion he’d nurtured since his college years at Princeton. His father, a pragmatist, advised him to obtain his medical degree, telling him (in advice that sounds very familiar) that he would not “write worse for having it.”

To help him solve these problems, Gibbon turned to the IBM Corporation, whose chairman, Thomas Watson, was the father-in-law of one of his students. With the aid of IBM’s engineers, Gibbon refined his machine:

At the University of Toronto, William Mustard developed a machine that used isolated rhesus monkey lungs to oxygenate the blood. At Wayne State University in Detroit, Forest Dodrill and engineers from General Motors built a heart pump that looked very much like the engine in a Cadillac. At the Mayo Clinic, John Kirklin and his colleagues constructed a heart-lung machine based on Gibbon’s design that used a vertical oxygenator and roller pumps

In the eighteenth century, for example, John Hunter, physician to King George III, intentionally injected his own penis with the purulent discharge of a patient with gonorrhea to investigate the transmission of that disease, contracting both gonorrhea and syphilis (the patient apparently had both).

In 1956, nearly three decades after Forssmann’s seminal experiment, Cournand, Richards, and Forssmann shared the Nobel Prize in Physiology or Medicine “for their discoveries concerning heart catheterization and pathological changes in the circulatory system.”

Coronary arteries are small, hardly five millimeters in diameter. When they are diseased with fatty plaque, their diameter can shrink to microns.

(As is so often true in medicine, treatment outpaced understanding.)

Doctors, for example, did not know that myo cardial infarction was caused by total or near-total obstruction of a coronary artery. (This mechanism wasn’t even mentioned in popular literature until 1955, when Humbert Humbert in Lolita is said to die of a “coronary thrombosis.”)

Franklin Delano Roose velt was in poor health for much of his presidency, even though his doctors, his family, and even journalists colluded to portray him as the picture of health. (Few in the public knew, for example, that Roose velt was essentially confined to a wheelchair after contracting polio when he was thirty-nine.)

When Roose velt began his second term in 1937, his blood pressure was 170/100 (normal today is considered less than 140/90). When the Japanese bombed Pearl Harbor in 1941, it was 190/105. By the time American soldiers landed in Normandy in June 1944, it was 226/118, life-threateningly high.

Snow was born in the town of York, at the intersection of two rivers contaminated by dung and sewage.

True to his meticulous nature, Snow also studied Soho residents who did not contract the disease—for example, inmates at a nearby prison that did not use the Broad Street pump, as well as brewery workers whose supervisor, a Mr. Huggins, told Snow that his men drank only water from the brewery’s own well (when they weren’t consuming the malt liquor they produced).

a founder of the Office of Malaria Control in War Areas (later known as the Centers for Disease Control, or CDC),

In the late seventeenth century, Framingham was a farming community, home of the first teachers’ college and the first women’s prison, and a haven for those trying to escape the witch hunts in nearby Salem.

Therefore, the Framingham study, as it emerged in the 1950s, was “clinically narrow,” as one researcher put it, “with little interest in investigating psychosomatic, constitutional, or sociological determinants of heart disease.” This would turn out to be a major flaw.

By the early 1960s, a definitive association had also been made between cigarette smoking and heart disease. (Smokers in previous studies hadn’t lived long enough to draw definitive conclusions.)

Today in South Asia, a large percentage of heart attacks occur in men with zero or only one Framingham risk factor. Over the past half century, coronary artery disease rates have increased threefold in urban India and twofold in rural India.

For example, consider heart disease in Japanese immigrants. Coronary artery disease is relatively rare in Japan. However, its rate is almost double in Japanese immigrants who settle in Hawaii and triple in those who settle in the mainland United States.

The type A link to heart disease has not stood up to modern investigation and is now generally considered an artifact of its time. More recent research has focused on the association of “negative affectivity” traits, such as depression, anxiety, and anger, with heart disease.

Today a massive amount of epidemiological data associates heart disease with chronic emotional disorder—or disruption of the metaphorical heart. For example, individuals in unhappy marriages are at a much higher risk for heart disease than those in more joyous unions.

Sones topped the charts. He routinely worked until midnight, holding his cigarettes with sterile forceps while he smoked in the cath lab. Then, instead of going home to his wife and children, he’d peel off his stained white undershirt and go out for drinks at a nearby hotel. Nurses and secretaries were known to hide from him in the ladies’ bathroom. He’d soon catch on, pounding on the door whenever he had a task that demanded their immediate attention.

Patients with heart failure mostly die in two ways: either by a sudden, “lights out” arrhythmia, in which the heart abruptly stops, or by progressive pump failure, in which the heart weakens to the point that it cannot deliver adequate blood and oxygen to the tissues.

In ventricular fibrillation, the heartbeat is so rapid and irregular that effective pumping of blood ceases to the brain, lungs, and other vital organs, resulting in a precipitous drop in blood pressure and the almost immediate onset of cell death.

The vulnerable period is crucial to understanding why normal hearts can self-electrocute. For example, when a healthy young athlete drops dead after getting a blow to the chest from a baseball or hockey puck, it is because the heart was hit during its vulnerable period.

“Steepening” of cardiac restitution may even be the mechanism behind “voodoo death,” the mysterious, sudden demise documented by anthropologists that often occurs during periods of intense emotional stress, such as after a witch doctor’s curse.

Greatbatch worked on the critical problems standing in the way of permanent cardiac pacing: battery life, proper insulation, and rising stimulation thresholds requiring higher and higher current to control the heart over time. (In the pro cess, Greatbatch invented the first long-lasting lithium battery, still in use today.) By the late summer of 1959, Greatbatch had used up his personal savings of $2,000 to handcraft fifty implantable pacemakers.

Despite public campaigns to increase organ-donor awareness, the number of available organs has remained relatively constant over the years (in part because of seat belt and motorcycle helmet laws that have resulted in fewer road fatalities).

But all medical technology carries a different price. Artificial hearts cause blood clots and disabling strokes. Dialysis saves lives but often results in painful, even life-threatening, infections. For implantable defibrillators, designed to deliver peace of mind, one of the biggest downsides, paradoxically, is fear.

We now know that 12 percent of cardiovascular deaths and 14 percent of myo cardial infarctions probably occur during sleep, even though victims are ostensibly resting.

South Asians seem to have smaller coronary arteries than other ethnic groups, which may result in more turbulent blood flow and wall stress that can initiate atherosclerosis.