In the Hands of Any Fool

In 1985, not long before he died of doctors in the hospital of the Soviet Academy of Sciences, the Russian astronomer Josef Shklovsky took his own pulse to save the doctor the trouble. ‘Seventy-three,’ he reported. The doctor was not merely ungrateful but contemptuous, for the pulse rate, she informed her illustrious patient, is always an even number. On looking into the matter, Shklovsky discovered that she had been taught to time for half a minute and double the result. It was another astronomer, Johannes Kepler, who first used a clock to time the pulse. He found a figure of round about seventy, but believed that the true answer must be 60 – one beat per second – for he could then relate it to the movement of the celestial clockwork.

That was in the 17th century. Now medicine has become, in the words of Lewis Thomas, the youngest science; and the kind of wanton incompetence that did for Josef Shklovsky has passed into history, at least in the West. Or has it? In 1983, the Journal of the American Medical Society published the results of a study on 100 deaths, all shown at autopsy to have been caused by heart attacks. It transpired that nearly half the cases had been incorrectly diagnosed and of the wrong answers half had come from specialists in cardiology.

Peter Fleming’s absorbing history does not contain this sobering information, but then it stops at 1970 – and on an upbeat note, with the introduction of cyclosporin, the immunosuppressant drug, and an improved outlook for heart transplant patients. What does, however, emerge from his narrative is the dogged resistance of doctors through the ages to new discoveries. As J.K. Galbraith once observed, most people, confronted with the option of changing their minds or proving they have no need to, get busy with the proof. For doctors this universal preference is compounded by the implication, in any confession of error, that patients have died. Another thread that runs through Fleming’s story is the conflict between the dictates of science and the cherished mystique of the healing art. Even the younger proponents of the so-called New Cardiology, which took shape in Britain in the Twenties, were reluctant to embrace the sphygmomanometers that had become available for the accurate measurement of blood pressure. Sir James Mackenzie, the patron, and Thomas Lewis, the leader of the scientific school and as much a physiologist as a physician, still held that ‘the trained finger’ was the best instrument for measuring arterial pressure.

Science made perhaps its first incursion into clinical cardiology with Laënnec’s invention of the stethoscope early in the 19th century. Doctors (some of them at least) took to listening (auscultation) and tapping (percussion). Some got carried away by the excitement of it all: Laënnec’s compatriot, Paul Louis Duroziez, thought that the left ventricle was the male part of the heart, being calm and stable, and the right ventricle the female, for it was nervous, impressionable and easily disordered. There had been advances in cardiac physiology long before Laënnec, based in the main on animal experiments, most often of a disagreeable nature. Here appeared the first of the ethical problems that were to beset the field for two centuries. Dr Johnson railed against the experimenters who inflicted cruelty on animals to gratify their own curiosity. He argued in much the same terms as the animal rights groups today: he knew, he said, of no discovery resulting from vivisection by which any illness could be more easily cured. These practices, moreover, ‘harden the heart, extinguish those sensations which give man confidence in man, and make physicians more dreadful than gout or stone’. And of the Rev. Stephen Hales – the country curate who, in a series of remarkable experiments, first measured blood pressure and flow rates on retired horses – Pope wrote: ‘he is a very good man, only I’m sorry he has his hands so much imbued in blood.’ Nevertheless, Pope added, ‘he commits most of these barbarities with the thought of being of use to man.’ The anti-vivisection movement gathered impetus in the 19th century, but there was no getting away from the necessity of animal experimentation. Many British physiologists accepted this, while declining to engage in it themselves. ‘Tais-toi, pauvre bête,’ François Magendie, whose physiological demonstrations to medical students in Paris attracted particular opprobrium, used to say to the dog writhing under his knife. Magendie’s pupil, Claude Bernard, perhaps the greatest physiologist of his time, was hounded by an outraged public, among them his own wife and daughter.

In the 19th century cardiology went quiet, for it had become clear to most doctors that they were almost powerless to combat heart disease. ‘If nothing is to be done, do nothing’ was how one mandarin of the profession put it – sensible advice, says Fleming, at any time. Autopsies had yielded some correlations of cause and effect. Edward Jenner (as well as developing the cow-pox vaccine) may have been the first to identify calcification of valves and arteries with angina. He was probably deterred from making this known by fear for his revered teacher, John Hunter, who was already suffering from the condition and was shortly to die of it. The irascible Hunter was said to have keeled over during an argument with a colleague. ‘My life is in the hands of any fool who cares to upset me,’ he had said awhile before.

Until about the end of the 18th century the only treatment for dropsy, which had been recognised as a sign of cardiac insufficiency, was to administer squill, a plant extract of repulsive taste and unpredictable diuretic properties. Dr Johnson in his last illness treated himself with huge quantities of it: five days later, ‘after he revolted against the taste of Squills, a sudden and unaccountable discharge of 22 pints of Urine came on.’ A little later still, after further doses, his oedema had vanished; but it was soon to return. In desperation, on the day before his death, Johnson tried, to the dismay of his friends, to relieve it by making three deep incisions in his legs with a lancet, believing that the dropsy was the disease itself, rather than its symptom.

Johnson had also been given digitalis, which was then still an experimental drug, but to this day perhaps the single most important means of controlling heart failure. As the 19th century progressed, other drugs came into use. Peter Latham, one of Fleming’s heroes for his cautious scepticism and his willingness (rare in the profession) to admit ignorance, recognised the nature of rheumatic heart disease. He treated it with the mercury compound calomel, together with opium to mitigate the side-effects and relieve pain. This was at a time when the cause of death, as in the case of George IV, could still be described as a ‘gouty heart’. Not long afterwards, amyl nitrate and nitroglycerine were introduced; and, like digitalis, they are still in use today.

The urge to try daring new treatments on heart patients, rather than let the disease take its course, has been an enduring source of ethical debate. Until a hundred years ago, cardiac surgery was generally held to be an impossibility. Theodor Billroth, the most respected surgeon of the day, denounced efforts to suture the heart as criminal. Nevertheless, several such efforts were reported, and no doubt there were many unrecorded attempts to repair wounds to the heart, all of which ended badly. Then, in 1903, the notoriously audacious Ferdinand Sauerbruch in Berlin discovered in mid-operation that what he had taken for a cyst on the heart was an aneurysm (a local distension of the weakened muscle). He cut it away and sewed up the hole; the patient lived, and thus began the new era of cardiac surgery.

Forty years earlier, the great French physiologist, Etienne Marey, had inserted a catheter through the jugular vein into the heart of a horse, measured the pressure in the compartments and tested the effects of digitalis, with no apparent detriment to the animal. It wasn’t until 1929, however, that anyone found the resolve to do this to a human subject, and then it was a young German hospital doctor, Werner Forssmann, who did it to himself (feeding the catheter through a cut in the vein at his elbow) after his chief had forbidden him to try it on a dying patient (or on himself for that matter). In 1956, he shared the Nobel Prize with two American cardiologists, who had catheterised many patients (but never themselves).

World War One confronted the doctors with new problems, for the stress and privations of life in the trenches generated a range of disorders. In the military hospitals only two heart conditions were recognised: VDH (valvular disease of the heart) and DAH (disordered action of the heart), also known as ‘soldier’s heart’ (which made it sound about as serious as housemaid’s knee). The New Cardiologists were active in studying the survivors, and a hospital for the treatment of soldiers with heart problems was set up in London. This gave an impulse to the development of the speciality – much derided by the more traditionally minded members of the profession, who objected to the implication that one could treat the heart, rather than the patient. Statistics on the mortality of patients in most areas of medicine, according to whether they are treated by specialists or by generalists, have now repeatedly shown the error of this judgment. The argument between the old and new schools of cardiology continued through the Twenties and Thirties, hingeing mainly on whether heart failure results from the incapacity of the heart to discharge its contents because of an obstruction (forward failure) or from inadequacy of the pumping mechanism. At the same time, diagnostic techniques improved rapidly, electrocardiography (first used in the previous century) especially.

Dr Fleming, himself a distinguished cardiologist, has told his story with authority and style, and has brought the protagonists, the great, the good and the foolish, deftly to life. He does not make many concessions to ignorance: if you do not know what mitral stenosis is, you will need a good dictionary at your elbow as you read. Fleming remarks in his Introduction that he has found it difficult to avoid the sin of Whiggishness, of ‘hunting for the present in the past’. This is perhaps a special problem in the history of science, for every advance has easily discerned antecedents. The stream of discovery flows, sometimes sluggishly, sometimes in a torrent through Fleming’s pages. Ernest Starling, a physiologist who contributed a great deal to the understanding of heart function, took the view that the merit attaching to the act of discovery is invariably overstated: ‘Every discovery,’ he wrote, ‘however important and apparently epoch-making, is but the natural outcome of a vast mass of work, involving many failures, by a host of different observers, so that if it is not made by Brown this year it will fall into the lap of Jones, or of Jones and Robinson simultaneously, next year or the year after.’ The paymasters of science had only ‘to ensure that the growing tree of knowledge is dug around and pruned, dunged and watered’. The precept, sadly, is seldom heeded today.

We are now in the age of scientific, hi-tech medicine. Machines do not make mistakes, spares can be bought for worn-out hearts and doctors have to contend with better informed patients, who cannot be fobbed off with evasions. With any luck. Not long ago a friend reported a conversation in a village pub. His circle of cronies had just lost one of their number, who had displayed all the classic symptoms of a heart attack. His doctor had assured him that it was no more than a severe bout of indigestion and advised him to go home and enjoy his Sunday lunch. This he did and then sank into a chair and died. ‘Ah, well, doctor must have known his time had come,’ one of his friends remarked. Perhaps such stoic acceptance is better than the more widespread belief that death is an option to be rejected. Even cardiologists would do well to remember the most cogent of famous last words, spoken by the 18th-century surgeon, Joseph Henry Green, while feeling his own pulse: ‘Stopped.’