Broken Hearts: The Tangled History of Cardiac Care by David S. Jones (review)

Much of the history of cardiology as a discipline and, certainly, cardiac surgery can be encompassed by the twentieth century. Indeed, many of the principal actors in this medical saga were still alive until just a few years ago. The main events have been captured in historical works, mainly by cardiologists and cardiac surgeons. These have been supplemented by recorded interviews with major figures and often revealing memoirs. Given the magnitude of the progress made in the field, it is not surprising that some hagiographic elements have crept into some of these accounts.

In Broken Hearts: The Tangled History of Cardiac Care, David S. Jones, a historian with a background in psychiatry, offers a different approach, with an expressed goal of “bringing social science perspectives to the problems of disease and therapeutics” (p. 17). He confines the scope of this work to the history of coronary heart disease and mainly the surgical approaches to its treatment.

The book is divided into two essentially equal parts. In the first, Jones traces the pathological history of the essential lesions within the coronary vascular tree. Although he has omitted a few significant nineteenth-century European publications on the subject, once the primarily Anglo-American period of the twentieth century is reached, Jones demonstrates a prodigious effort in tracing the progression in our knowledge of the atherosclerotic process, finally culminating in our understanding of the vulnerable plaque, with its disruption leading to coronary thrombosis and myocardial infarction. Anyone interested in exploring this part of medical history would do well to consult his extensive bibliography.

There are a few factual errors. In 1929, when Werner Forssmann performed the first human heart catheterization—on himself—he was not a cardiologist, but a surgical house officer. It was not a plastic tube he threaded up his arm vein but a ureteral catheter. And no radiopaque material was injected to assist in visualizing the tip of the catheter in his right atrium when X-ray documentation of the feat was performed. It was later on in his career that Forssmann promoted the use of such material. Fortunately, such lapses are few and far between.

It is in the second part of the book that Jones comes into his own, utilizing his training both as a psychiatrist and historian. Ominously titled “Complications,” this section, in less judicious hands, might have presaged some serious physician bashing. To his credit, Jones remains evenhanded, pointing out the difficulty in making therapeutic choices. The emphasis here is on cerebral complications of embolic phenomena associated with different types of surgery and angioplasty. The problems, neurologic and psychological, inherent in the use of the heart–lung machine are also emphasized. In this context it would have been suitable to mention the role of hypothermia as it was used in open heart surgery as the sole method of brain function preservation as well as its use in association with the heart–lung machine up to the present.

Even more desirable would have been Jones’s addressing the problem of sudden unexpected death from lethal arrhythimas unassociated with coronary thrombosis. Many coronary patients die in this way after recovering from one or more myocardial infarctions, and it would by edifying to see what Jones would have to say about this aspect of coronary mortality and means to combat it with cardiac resuscitation efforts, automatic implantable defibrillators, and drug therapy. “Sudden death” is alluded to frequently throughout the book, but no specific focus on it is made. “Ventricular fibrillation” does not appear in the index.

Perhaps the best part of the book is found in the final chapters, where Jones deals with geographic differences in practice and points out how the individual effects of race, economics, and other factors come into play with our approach to coronary disease as either patients or physicians. His message is that there is “a marked asymmetry in medical knowledge in which there is more evidence...