The shout of “CLEAR!” is ubiquitous on television medical drama; it seems we universally fear and dread the infamous “heart attack.” And we should. Cardiac disease remains one of the biggest killers worldwide, and yet, until the very recent past, physicians did not know what caused them or how best (and if and when) to treat them.
David S. Jones‘ book Broken Hearts: The Tangled History of Cardiac Care first appeared in 2012. I was lucky enough to hear Dr. Jones speak at the Dittrick Medical History Center that following year–right here in Cleveland, Ohio, where many of these medical innovations took place. Claude Beck (1894-1971) devised ways to revive heart attack victims with the use of carefully controlled electricity, but Beck’s defibrillator cannot be isolated from two other innovations, the Kay-Cross Oxygenator and by-pass surgery (also developed in Cleveland and on display at the Dittrick, by the way). Oxygenators allowed for stopped-heart surgery and more delicate operations, while the defibrillator allowed doctors to re-start the heart. Then in 1958, F. Martin Sones discovered moving cine-coronary angiography, a technique for visualizing the inside of the coronary arteries, but all of these “firsts” were accomplished through risk-taking, a hallmark of Cleveland successes generally. What made the risks worth it?
David Jones calls it a slow motion rise and fall—the “epidemic” of heart disease was less a new development than a constellation of events: changing social and economic conditions (rise in cigarettes, change in diet, exercise, stress, pollution) but also income inequality…plus new diagnostic tools that let us “see” the heart and diagnose it better. And of course, the fact that it was a “business man’s” disease meant a greater focus upon it, while increased competition among and between institutions meant that suddenly, heart disease was at the center of everyone’s attention.
Jones points to this rise as instructive; once understood as an epidemic, physicians began to use surgical interventions not only as a means of helping a patient, but also as a diagnostic in the search for disease causation. What really caused the problem and what were the best means of curing it? Plaques…or ruptures…or clots? (In the end, it’s really all three, and Jones explains the differences between types of infarction with incredible clarity). Not surprisingly, diet and lifestyle were factors well beyond the control of doctors. Patients wanted internal solutions, quick fixes, “miracles” of medicine. Enterprising doctors wanted the same. Jones’ points to the “ambiguities and inconsistencies” in medical decision making, and also how this affects perception not only of doctors but of the wider culture. His research causes us to reflect on why surgical interventions become “over-sold” in terms of their efficacy.
At the 1969 annual meeting of The Society of Thoracic Surgeons, Dr. Effler stated, “Only a few years ago papers on [myocardial revascularization surgery] were viewed with frank skepticism and the authors looked upon with suspicion…. [but] The subject of myocardial revascularization is timely and deserves more attention at surgical meetings.”1 He had reasons to be bold; a year earlier, Dr. Effler and his colleagues performed the first cardiac transplant in the Midwest. But Just because a surgical intervention may be performed doesn’t make it a good idea. Jones describes the neurological problems following heart lung machines, and the considerable risks of the surgeries themselves. Angiography was not always a clear picture. Some surgeries may not have been necessary. Others were undertaken but the outcomes were less advantageous than hoped. Jones’ work shows how the realization of risk led to new technique, things we take for granted today but which came about in the 60s and 70s as a result of the “epidemic” of heart disease. And risk matters. Effler lost 5 of his first 11 patients. Death was, as Jones puts it, “woven into the field.” People were ready to take risks, and there wasn’t always consensus about what risk really meant. More animal trials, or not? Risk this patient or not? Risk this procedure or not?
The answer is not an answer. It’s a story. Imagine a surgery where doctors operate with the knowledge of high mortality rates if you do, but also with the certain death of patients if you don’t—with the neurological complications that plagued procedures— with only an imperfect understanding of what caused heart attack—and with the knowledge that your team was at the forefront as path breakers. What would it be like to make decisions in that context? And in what ways are we inheritors of that time period and that rhetoric? Jones’ research, carefully collected, expertly handled, and easy to read even for non-specialists, demonstrates not only the complexity of the disease itself but also the convoluted and politicized means by which treatment decisions are made. And re-made. And re-made. Why and how doctors (and patients) overestimate the effectiveness of medical interventions lies with a nexus of competing interests and aims, with a rhetoric of success that belies complications, and with the very interventionist model that aided original research into coronary disease and the causes of infarction (heart attack).
As both an M.D. and Ph.D., Jones has a perceptive eye and a wide lens on history. His meticulous research into archives and clear presentation make this book a public history with academic fervor. He is now at work on a follow-up, On the Origins of Therapies, which will trace the evolution of coronary artery bypass surgery.