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Review of books

August 2007
spiked review of books
The matter of the heart

Josie Appleton

The matter of the heart

It’s mere organic matter, a bundle of muscle that pumps blood around the body. So why throughout history has the heart been seen as the seat of all that is vital in human life?

For millennia, people have known that if the heart is ‘alive’ – beating – then we live. And if it dies, we die too. As a result, the heart has long been seen as the seat of all that is most vital, and most dramatic, in human life.

The Heart – a book of essays and interviews edited by James Peto, which accompanies a Wellcome Collection exhibition in London on the cultural and medical history of the human heart – shows the layers of meaning which have been projected on to this small organ.

In ancient times, all the intensities of experience were seen as originating in that bundle of muscle, from love to anger, passion to pride. Hearts, it was thought, could reach extremes of hot and cold as they drove the emotions, boiling to cause anger or cooling to cause melancholy. In Egyptian myth, a person was judged after death by the weighing of his heart: if the deceased’s heart did not pass the test, he would not continue to the afterlife.

On a still grander scale, people have drawn connections between the heart and the forces of the cosmos. The Aztecs ripped out their victims’ still-beating hearts in an attempt to keep their crops growing, believing that vital sun-energy was concentrated in the heart, and that by sacrifice they could recycle this force for the benefit of the living.

Some might see the development of medical science, and eventually heart surgery, as a process of disenchantment. The heart is reduced to a diagram in science textbooks, with its four chambers and valves, and lines showing the direction of blood flow. One surgeon described the heart transplant as ‘quite a simple plumbing job’. An essay in The Heart, by the historian Fay Mound Alberti, laments the fact that medical science transformed the heart into a mere pump, an ‘objectified muscle, subject, like any other, to disease, dysfunction and decay’, and wonders whether its grand emotions will ever be returned.

While past priests of the heart were revered, heart surgeons are now often presented as egotistical control-freaks. ‘There is an assumption that we are all on the golf course driving Bentleys’, notes one of the surgeons interviewed in The Heart. Indeed, the UK government seems to think heart surgeons are in need of official league tables and targets, to encourage them to take proper care of their patients.

Yet the interviews and essays in this book show how the medical exploration of the heart, bit by gruelling bit, has required the greatest imagination, perseverance and humanity. Heart transplants are often performed in the middle of the night, conducted to the ticking clock that is the donor heart’s limited lifespan outside a human body. Francis Wells, a consultant cardiothoracic surgeon, describes the tension and immediacy of operating:

Real vitality exists within the developing individual, and his relationships with others

‘Every time you embark on an operation, you know that you’ve got to get it right…. Every time you step up to the plate to do one of these operations – whether you’re not feeling so good, whether you’re tired, or you’ve got some disaster in your life – you’ve still got to raise your game to that level of near perfection.’

They know that a wrong cut means the death of their patient, whose family and loved ones are waiting down the corridor. Being a cardiac surgeon means experiencing the joy of saving a life – the book is full of interviews with patients who became competitive swimmers, brought up their children or went to university thanks to their new heart – and the disappointment of an operation that fails. Martin Elliott, a surgeon at Great Ormond Street Hospital, talks about the self-questioning that ensues after operating table deaths: ‘[Y]ou think, “Well, did I make a cock up? Did I do this?”, which, of course, is what surgeons think first of all…. “Would somebody else have done it better? Could I have called someone? What didn’t I know? Why didn’t I know it?”’

If anything, growing league tables, targets and bureaucracy threaten to undermine these genuine sources of pressure on the surgeon, which are based on the weight of another person’s life in your hands, and the trust that this entails. Francis Wells describes how ‘that bond of trust is paramount: both the patient putting their trust in your hands, and you accepting that gift of trust and making the most of it to do the best for the patient’.

In response to the first heart transplant, one commentator lamented that ‘the ultimate symbol of human affection is reduced to a clinical convenience’. In fact, knowing the heart as a muscular pump has not stripped the emotion away, but rather has returned emotion to its proper seat: the human personality. We know now that the heart itself is not the vital force of life, but merely a means for keeping a person alive. Vitality proper exists within the developing individual, and in the individual’s relationships with others.

Of course, we still describe emotion as located in our heart – we say that we know something ‘in our heart of hearts’, or we care for someone ‘from the heart’. But this is a different heart to the one that science deals with. About the same time as scientific medicine stripped the heart down to its muscles and nerves, there developed a new romantic idea of the heart, as the seat of inner truth. If in ancient times there was the vital heart, in modern times this heart split into two hearts: the physical heart-as-pump, and the metaphoric heart-as-inner-life.

Yet the discovery of the heart-as-pump was not a dry and technical process; medicine’s journey was ripe with drama. The diagram of the heart may look simple and a bit dull in textbooks, but it took struggle and detective work to penetrate the organ’s secrets. A superb essay by physician Jonathan Miller shows the difficulties encountered by those trying to work out the heart’s beat. Now, pictures of the heart show the different blood vessels illustrated neatly in different colours, but when men first looked into the human chest it was a tangle of bloody tissue and vessels, and it took over a millennium to work out how it functions. For ages people believed, for example, that air entered the heart directly, in part because the blood had drained from the hearts of subjects by the time scientists reached them. William Harvey – who eventually cracked the question of how the heart pumps blood – told of his perplexity at opening the chests of living mammals to observe their beating hearts.

‘I kept finding the matter so truly hard, so beset with difficulties that I all but thought…that the heart’s movement had been understood by God alone. For I could not rightly distinguish…[when] or where constriction and dilation occurred. This was because of the rapidity of movement, which in many animals remained visible for but the wink of an eye or the length of a lightning flash.’

Even without the technical difficulties, Jonathan Miller explains how the task of observing biology is never obvious. We often need theories before our eyes can pick out details – for example, to distinguish a blood vessel from a vein. It was only as understanding crept forward that scientists were able to dissect and disentangle the organ before their eyes.

In the book’s conclusion, science writer Jon Turney speculates that in the future there could be an entirely artificial heart. Only this would be a heart with a difference: it would not have a pulse. The human heart must have a pulse because it is contracting muscle, but a machine could circulate blood using a rotary system. For us, the heart’s pulse is still identified with our sense of vitality, and so we might find this idea strange. Can we imagine living ‘without a pulse’? But these are similar fears to those that accompanied the development of heart surgery, when one transplant patient’s wife worried whether he would still love her after surgery. Our vitality lies in the living personality, not in the contracting muscle – so life without a heartbeat would be no less dramatic than it is today.

Josie Appleton is convenor of the Manifesto Club. Email her at .(JavaScript must be enabled to view this email address).

The Heart by James Peto (ed) is published by Yale University Press. (Buy this book from Amazon(UK).)

For permission to republish spiked articles, please contact Viv Regan.

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