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Pump action: the heart-stopping history of cardiac surgery

Thomas Morris's book The Matter of the Heart is not for the squeamish.

In 1628 William Harvey, the king’s physician, published De motu cordis, proving that the heart was not the seat of the soul, but a pump. “The animal’s heart is the basis of its life, its chief member, the sun of its microcosm,” he wrote in the book’s dedication; “on the heart all its activity depends, from the heart all its liveliness and strength arise.” Harvey was a skilled and dauntless anatomist (he dissected his own sister and father), unafraid to challenge orthodoxy.

In 1641 he was sent by Charles I to see an 18-year-old nobleman, the eldest son of Viscount Montgomery, rumoured to have a persistent wound through which the lungs could be seen. When Harvey looked into the boy’s chest he was astonished to see not the lungs, but the heart: “the apex of the heart! covered over with a layer of fungous flesh”. He poked in “three of my fingers and my thumb”, becoming the first person on record to handle a living human heart. He promptly took the boy to see the king. “And his most excellent Majesty, as well as myself, acknowledged that the heart was without the sense of touch; for the youth never knew when we touched his heart . . .” As a medical student watching cardiac surgeons at work, I had a glimpse of Harvey’s wonder. That the heart, the source of “all . . . liveliness and strength”, could be exposed, stopped, manipulated, replumbed and restarted seems among the most astounding of modern medicine’s marvels.

Thomas Morris has written not a history of medical ideas about the heart, but a history of heart surgery. He nods to Aristotle, to Pliny, even to the French Renaissance surgeon Ambroise Paré, but it is with Harvey and his inquisitive sovereign that The Matter of the Heart really begins. “Here was clear evidence that the organ could be handled without danger,” Morris observes, “yet strangely this knowledge had already faded from view two centuries later.”

Occasionally through the 18th and 19th centuries, individuals survived stab wounds to the heart. Surgeons in the city of Rome became adept at speed-suturing heart muscle after dagger wounds (owing, Morris writes, quoting a contemporary, to “the terrible frequency with which the dagger is resorted to in this country in the quarrels of the lower orders”). During the Second World War Dwight Harken, a US surgeon based at a military hospital in Gloucestershire, perfected the technique of removing shrapnel and bullets from the heart, performing 134 operations on soldiers without a single death.

In an early chapter Morris discusses how surgeons have approached cardiac malformations. The heart forms in the first days of embryonic life from two tubes that coalesce and then coil themselves into a steadily thickening knot. When the process falters the result can be a heart that mingles bluish, deoxygenated blood from the body’s circulation with red, oxygenated blood from the lungs. This makes for an inefficient pump, which is exhausting for the child; untreated, it can also lead to heart failure and death. The author tells the absorbing story of Alfred Blalock, Helen Taussig (one of the few women in this story) and Vivien Thomas, who, collaborating at Johns Hopkins in Baltimore, developed the first procedure to give “blue babies” a better mix of oxygenated blood. He also writes of Robert E Gross, who in Boston in 1938 pioneered a procedure by which surgeons tie off a “patent ductus arteriosus”. (If the heart knots itself into position, a patent ductus can be imagined as a thread left untied.)

The stories come quickly: fluent, wry, admiring. In a chapter on aortic aneurysms (swelling of the aorta) is Giovanni Morgagni, an 18th-century Italian anatomist who diagnosed a syphilitic aneurysm in a prostitute who had died suddenly, “lying in such a posture that it could not be doubted what business she had been engaged in”. Einstein, too, died from a ruptured aorta, after surviving five years with cellophane wrapped around his aneurysm to reinforce it. He declined a second repair, telling his surgeon, Rudolph Nissen: “I have done my share; it is time to go. I will do it elegantly.”

To operate on the heart, it is necessary to terminate its beating for a while, but to do this, ways had to be found to support the circulation. The 17th-century polymath Robert Hooke was first to suggest that such a “cardiopulmonary bypass” might be possible, and in the 1950s it became a reality. Before bypass machines were refined, children undergoing surgery sometimes had their hearts plumbed into their mother’s or father’s circulation, the parent’s heart beating for both throughout the procedure. This didn’t catch on, being “the only procedure with a potential mortality of 200 per cent”.

The Matter of the Heart is being published to coincide with the 50th anniversary of Christiaan Barnard’s infamous first transplantation of the human heart. Much of it makes grisly reading, not just for the scores of human deaths it recounts, but for the many thousands of animals, mostly dogs, sacrificed to the development of modern cardiac surgery. Barnard was inspired to transplant a human heart after hearing of a Russian maverick called Vladimir Demikhov, who transplanted heads of live puppies on to adult dogs, “creating a two-headed beast” that could survive for up to four weeks. Barnard was a latecomer to cardiac transplantation, implementing the groundbreaking work of the Americans Norman Shumway, Richard Lower and Adrian Kantrowitz – in the far less ethically regulated environment of South Africa.

Cardiac transplantation takes up just one chapter among 11. Scores of ­innovations have found their way into this book. It explains the origins of artificial valves, both of pig tissue and of metal; the invention and development of pacemakers (powered by batteries and by plutonium), as well as the origins of bypass grafting, aneurysm coiling and coronary stenting. Morris seems anxious not to leave anything out, and the result will be too encyclopaedic for some – as dogged and meticulous as you would expect from a former producer of Radio 4’s In Our Time. In many ways, it is a broadcaster’s book, no description appearing without its superlative, in this “world of microscopic precision and miraculous engineering in which life-threatening heart conditions” are relieved.

But after two years camped out at the Wellcome Library on the Euston Road in London, and also trawling archives from Maryland to Oregon, Morris has made something unique: a history less of people than of procedures, but lively, enthusiastic and brimming with detail. I didn’t know that cyclosporine, which renders human transplantation possible, comes from a fungus found in Norwegian mud. And who knew that the drug which keeps stents open comes from soil on Easter Island? Or that an artificial, nuclear-powered steam-pump heart was once developed, so radioactive that it would sterilise the gonads of anyone standing nearby?

When I was in medical school, I was as stunned as William Harvey to see an exposed beating heart: “that, in a man alive and well, he might, without detriment to the individual, observe the movement of the heart”. Now Morris tells me there’s a Perspex box called the Organ Care System, which keeps the heart warm, perfused and pumping artificial blood for up to eight hours in transit. The final chapter of The Matter of the Heart explores innovations yet to come: farms breeding genetically modified pigs, their hearts rendered acceptable to the human immune system, or 3D printers that use cardiac cells for ink. In the end matter, the author thanks his partner for putting up with years of his “boring surgical anecdotes”. But “anecdote” doesn’t do them justice, and I would like to reassure Morris and the many readers who will enjoy this book: these stories are anything but boring. 

Gavin Francis’s book on human transformation, “The Shapeshifters”, will be published next spring by Profile

The Matter of the Heart
Thomas Morris
Bodley Head, 432pp, £20

This article first appeared in the 08 June 2017 issue of the New Statesman, Election special

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Social media tome #Republic questions the wisdom of crowds

Cass R Sunstein explores how insulation pushes groups towards more extreme opinions.

Cass Sunstein, one of the leading public intellectuals in the United States and a former Obama administration official, has worried and written for more than 15 years about the effects of the internet and digital communications on democracy. This book, his third on the subject, tackles social media.

The heart of his argument lies in the cumulative, collective effect of what individuals do online. Networking, shopping, dating and activism are all transformed by the engine of opportunity that is the internet. But those new links and choices produce a malign side effect: “filter bubbles”, inside which like-minded people shut themselves off from opinions that might challenge their assumptions. Insulation pushes groups towards more extreme opinions.

Sunstein’s organising principle is the ­difference between consumer and political sovereignty. The former promotes individual choice despite its possible consequences; the latter takes into account the needs of society as a whole. His inspiration is Jane Jacobs, the historian of US cities who celebrated, in poetic language, the benign and enriching effect on democracy of random encounters between citizens on pavements and in parks. How do we now reverse or dilute the polarisation driven by Facebook and Twitter?

The solutions Sunstein proposes for this very difficult problem are oddly tentative: websites stocked with challenging ideas and deliberative debates, voluntary self-regulation and “serendipity buttons”. He rightly stresses transparency: we know far too little about the algorithms that sift news for our attention on the networks. Facebook has talked about trying to show news that is “engaging” and “interesting”, without ever engaging in detailed public discussion of what these words mean. The disclosure requirements for social networks “require consideration”, Sunstein writes, without saying whether Facebook might have to be required legally to explain precisely how it routes news to almost two billion users.

Sunstein’s most interesting arguments are myth-busters. He questions the “wisdom of crowds”, while refraining from pointing out directly that the single strongest argument against this idea is the inequality of opinions. Not all opinions are equally valuable. He warily suggests what only a very few American voices have so far dared to say: that the First Amendment to the constitution, which guarantees a free press, should not be treated – as the courts have recently tended to do – as an equally strong protection for the freedom of all speech.

Sunstein is nostalgic for the media system and regulation of the past. I spent years working for a daily “general-interest” newspaper (the Times) and regret the decline of those outlets as much as he does, yet there is no reversing the technological and economic changes that have undermined them. It might have been a mistake to deregulate television in the United States, and killing the “fairness doctrine” might have had unforeseen effects, but that does not deal with the dilemmas thrown up by WhatsApp or Weibo, the Chinese version of Twitter.

Users of these platforms face the problem of managing abundance. Writers such as Sunstein imply that people who lock themselves in filter bubbles are deplorably unable to break out of their informational isolation. But we all now live in bubbles that we design to make sense of the torrent of information flowing through our phones. Better-designed, heterogeneous bubbles include the unexpected and the challenging.

Yet the problem lies deeper than the quality of your bubble. Polarised societies can no longer agree on how to recognise the truth. Filter bubbles play a part, but so do a preference for emotion over reason, attacks on scientific fact from religion, decades of public emphasis on self-fulfilment, and a belief that political elites are stagnant and corrupt. Like many journalists, Sunstein treats the problem of a malfunctioning communications system as a supply-side matter: the information being generated and distributed ought to be better.

In the case of fake news, that is indisputable. But there is also a demand-side problem, one that hinges on the motives of those consuming information. If, inside their bubbles, people are not curious about alternative opinions, are indifferent to critical thinking and prefer stoking their dislike – of, say, Hillary Clinton – will they have even the slightest interest in venturing outside their comfort zone? Do we have a right to ignore the views of others, or an obligation to square up to them? Millions of Americans believe that one of the most important guarantees in their constitution is the right to be left alone – and that includes being left alone by the New York Times.

Sunstein does not venture far into this territory. He only hints that if we worry about what people know, we must also worry about what kinds of societies we build. Globalisation has reshaped communities, dismantling some and building others online, but the net effect has been to reduce deliberation and increase a tendency to press the “Like” button, or loathe opponents you can’t see or hear. The ability to debate civilly and well may depend on complex social chemistry and many ingredients – elite expertise, education, critical thinking, culture, law – but we need to be thinking about the best recipes. 

George Brock is the author of “Out of Print: Newspapers, Journalism and the Business of News in the Digital Age” (Kogan Page)

#Republic: Divided Democracy in the Age of Social Media
Cass R Sunstein
Princeton University Press, 328pp, £24.95​

George Brock is a former managing editor of The Times who is now head of journalism at City University in London.

This article first appeared in the 22 June 2017 issue of the New Statesman, The zombie PM

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