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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

Terry Notary's simian appearance as performance artist Oleg in The Square
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Ruben Östlund’s film The Square hammers home the point that we are all still animals

 Each thread and simian guest star shows how little distance there is between the civilised and the primitive.

Yasmina Reza’s play Art, about three friends whose closeness is threatened when one of them spends a fortune on an entirely white painting, offered audiences a series of packaged talking points (Does objective taste exist? What is art?) for their post-theatre meal. Ruben Östlund’s film The Square, which won the Palme d’Or at Cannes last year, serves the same function. Before the first scene is over, the Stockholm curator Christian (Claes Bang), a vision of metropolitan spiffiness in his red-framed glasses, has already wondered whether an ordinary bag placed in a gallery would qualify as art. In his current exhibition is a room filled with piles of gravel. A visitor pokes his head in, decides there’s nothing worth investigating, then leaves. We’ve all done it.

Like the canvas in Reza’s play, there is a catalyst for disorder here: the blue neon square set into the gallery’s courtyard. It is conceived as “a sanctuary of trust and caring” but its arrival throws everyone’s behaviour into sharp relief. A woman screams for help as she is pursued by an unseen aggressor, prompting everyone around her to become more than usually engrossed in their phones. Charity workers ask commuters whether they would like to save a human life, only to be given the brush-off. Christian’s relationship with poverty is squeamish. He buys a sandwich for a homeless woman. “No onions,” she says. “Pick them out yourself,” he snaps, incredulous to find that beggars can also be choosers.

His downfall, which starts after he hatches a cockamamie scheme to retrieve his stolen wallet and phone by leafleting the housing estate where he believes the thieves are hiding, is the thread on which the film’s provocative episodes are hung. Each one, such as the gallery chef flying into a rage because no one wants to hear about his balsamic reduction, shows how little distance there is between the civilised and the primitive. A series of simian guest stars, real and pretend, make cameo appearances to hammer home the point that we are all still animals, no matter how many private views we attend. These include the performance artist Oleg (Terry Notary), whose confrontational appearance imitating an ape at a black-tie dinner – not just scene-stealing but film-stealing – exposes the instincts of the herd to conform, even if that means ignoring violence taking place at the next table.

That sequence crystallises ideas that in other parts of the film feel distinctly wishy-washy. Jibes about pretentious artists (a cameo from Dominic West) or crass advertising executives smack of the contrived bugbears of clickbait columnists – what next, jokes about quinoa served on slates? And a section of the film about a bad-taste campaign to promote the neon square will seem penetrating only to viewers who have never considered that ad agencies might stir up controversy for publicity purposes.

Östlund is sharper when he focuses on the discord beneath everyday social interactions, using sound and camerawork to disrupt supposedly simple scenes. He prefers when shooting a conversation, for instance, to linger too long on one participant, rather than cutting back and forth between them, so that we begin to interrogate and mistrust the face we’re looking at. Stand-offs between Christian and the journalist Anne (Elisabeth Moss), including an excruciating argument over a condom, show this technique at its most blissfully torturous.

He is a director who is never more comfortable than when he is making audiences squirm, as he did in Force Majeure, in which a man neglects his family but not his phone when fleeing danger. But the situation in The Square, which escalates to the point where Christian must ignore a child’s suffering in order to safeguard his own existence, would have greater moral force if the film showed any interest in its poorer characters as something other than lightning rods for middle-class complacency.

The Square is undeniably entertaining, though its lasting use may be to demonstrate that movies can have the same effect as popping a coin in the collecting tin. Having seen the film, you can rest easy knowing you’ve already given. You’ve done your guilt for this week.

The Square (15)
dir: Ruben Östlund

Ryan Gilbey is the New Statesman's film critic. He is also the author of It Don't Worry Me (Faber), about 1970s US cinema, and a study of Groundhog Day in the "Modern Classics" series (BFI Publishing). He was named reviewer of the year in the 2007 Press Gazette awards.

This article first appeared in the 13 March 2018 issue of the New Statesman, Putin’s spy game